The newborn infant physical examination (NIPE) aims to detect abnormalities in the newborn baby. It is performed within the first 72 hours after birth (by a trained midwife or doctor) and at 6 – 8 weeks (by the GP).
Principles
Wash your hands before and after the examination to minimise the risk of introducing infection to the baby. Explain, reassure, and keep the parents involved. Keep the baby warm and comfortable during the examination.
Every part of the body needs to be examined. Adequate exposure is required for a complete examination of the skin.
Start at the top of the head and work down to the toes. Take a systematic approach, but be opportunistic. For example, if the baby has its eyes open, it is a good opportunity to check the red reflex, and if it is settled, it may be a good time to listen to the heart sounds.
Before starting, ask the parents about any concerns or questions they may have. Ask:
- Has the baby passed meconium?
- Is the baby feeding ok?
- Is there a family history of congenital heart, eye or hip problems?
Oxygen Saturations
At the first newborn examination (within 72 hours of birth), the pre-ductal and post-ductal oxygen saturations can be checked. This measures the oxygen level before and after the ductus arteriosus. Normal saturations are 96% or above. There should not be more than a 2% difference between the pre and post-ductal saturations. Abnormal saturations require further investigation and potential admission to the neonatal unit.
The ductus arteriosus is located along the arch of the aorta and connects the aorta with the pulmonary artery. It normally stops functioning within 1-3 days of birth. It allows blood from the deoxygenated right-sided circulation before the lungs to mix with the oxygenated left-sided circulation after the lungs.
Certain congenital heart conditions (e.g., transposition of the great arteries) are duct-dependent, meaning they rely on mixing blood across the ductus arteriosus. When the ductus arteriosus closes, symptoms can rapidly deteriorate. Abnormal pre and post-ductal saturation can help detect these conditions before the duct closes.
Pre-ductal saturations are measured in the right hand. The right hand receives blood from the right subclavian artery, a branch of the brachiocephalic artery, which branches from the aorta before the ductus arteriosus.
Post-ductal saturations are measured in either foot. The feet receive blood travelling from the descending aorta, which occurs after the ductus arteriosus.
Examination Steps
General Appearance
- Colour (pink is good)
- Tone
- Cry
Head
- General appearance: size, shape, dysmorphology, caput succedaneum, cephalohaematoma and facial injury
- Head circumference: known as the occipital frontal circumference (OCP)
- Anterior and posterior fontanelles
- Sutures: overlapping sutures are common and usually resolve as the baby grows
- Ears: skin tags, low-set ears and asymmetry
- Eyes: slight squints are normal, epicanthic folds can indicate Down’s, purulent discharge could indicate infection
- Red reflex using an ophthalmoscope: check for symmetry, often more pale in darker-skinned babies, absent with congenital cataracts and retinoblastoma
- Mouth: cleft lip, tongue tie, check the palate to the uvula
Shoulders and Arms
- Shoulder symmetry: check for a clavicle fracture
- Arm movements: check for an Erbs palsy
- Brachial pulses
- Radial pulses
- Palmar creases: a single palmar crease is associated with Down’s (but can be a normal variant)
- Digits: check the number of digits and if the fingers are straight or curved (clinodactyly)
Chest
- Observe breathing: look for respiration distress and asymmetry, and listen for stridor
- Heart sounds: listen for murmurs, heart sounds, heart rate and identify which side the heart is on
- Breath sounds: listen for symmetry, air entry and added sounds
Abdomen
- Observe the shape: a concave abdomen may indicate a diaphragmatic hernia (abdominal contents in the chest)
- Umbilical stump: look for discharge, infection and a periumbilical hernia
- Palpate for organomegaly, hernias or masses
Genitals
- Observe for the sex, ambiguity and any obvious abnormalities
- Palpate testes and scrotum: check both are present and descended, check for hernias or hydroceles
- Inspect the penis for hypospadias, epispadias and urination
- Inspect the anus to check if it is patent
Legs
- Observe the legs and hips for equal movements, skin creases, tone and talipes (ankles turned inwards)
- Count the toes
- Barlow and Ortolani manoeuvres: check for clunking, clicking and dislocation of the hips
The Ortolani test is done with the baby on its back, hips and knees flexed. Palms are placed on the baby’s knees, thumbs on the inner thigh, and four fingers on the outer thigh. Gentle pressure is used to abduct the hips, and pressure is applied behind the legs with the fingers to see if the hips will dislocate anteriorly.
The Barlow test is done with the baby on its back, with the hips adducted and flexed at 90 degrees and knees bent at 90 degrees. Gentle downward pressure is placed on the knees through the femur to see if the femoral head will dislocate posteriorly.
Back
- Inspect and palpate the spine: look for curvature, spina bifida and a pilonidal sinus
Reflexes
- Moro reflex: when rapidly tipped backwards, the arms and legs will extend
- Suckling reflex: placing a finger in the mouth will prompt them to suck
- Rooting reflex: tickling the cheek will cause them to turn towards the stimulus
- Grasp reflex: placing a finger in the palm will cause them to grasp
- Stepping reflex: when held upright and the feet touch a surface, they will make a stepping motion
Skin Findings
Possible skin findings include:
- Haemangiomas: Benign vascular lesions, often regress spontaneously
- Port wine stains: Pink patches of skin, often on the face, caused by capillary abnormalities, persist long-term
- Blue-grey spots: Also called congenital dermal melanocytosis (previously “Mongolian blue spots”), more common in darker-skinned babies, benign
- Cradle cap: Seborrheic dermatitis, benign
- Desquamation: Normal skin peeling in term infants
- Erythema toxicum: Common, benign rash in the first week
- Milia: Small white cysts, resolve spontaneously
- Acne: Neonatal acne, benign
- Naevus simplex: “Stork bite,” fades with time
- Transient pustular melanosis: Benign pustules, more common in darker-skinned infants
Common Issues
Talipes, also known as clubfoot, occurs when the ankles are supinated and rolled inwards. It can be positional or structural. Positional talipes occur when the muscles are slightly tight around the ankle, but the bones are unaffected. The foot can still be moved into the normal position. Refer to a physiotherapist for some simple exercises. Structural talipes involve the foot and ankle bones and require an orthopaedic referral.
Undescended testes require monitoring and referral to a urologist if they do not descend by 4-5 months.
Skin findings generally do not require action. However, they should be documented for future reference (e.g., concerns about bruising in children with blue-grey spots). Many will fade with time.
Haemangiomas near the eyes and mouth or affecting the airway may require referral for treatment with beta-blockers (e.g., propranolol). Otherwise, they can be monitored and usually resolved with time.
Port wine stains are pink patches of skin, often on the face, caused by capillary abnormalities. They do not fade with time and typically turn a darker red or purple. Rarely, they can be associated with Sturge-Weber syndrome, which involves visual impairment, learning difficulties, headaches, epilepsy and glaucoma.
Clunky or asymmetrical hips require referral for a hip ultrasound to rule out developmental dysplasia of the hips.
Cephalohaematoma requires monitoring for jaundice and anaemia.
Bony injuries may require an x-ray for fractures (e.g., clavicular fracture).
Soft systolic murmurs of grade 2 or less in otherwise healthy and well newborns may be monitored, as they may resolve within 48 hours. This may be caused by a patent foramen ovale that closes shortly after birth. Any suspicion of heart failure or congenital heart disease requires referral to cardiology for an ECG and echocardiogram. If they are unwell, they require admission to the neonatal unit and immediate management.
Last updated May 2025
Now, head over to members.zerotofinals.com and test your knowledge of this content. Testing yourself helps identify what you missed and strengthens your understanding and retention.
