Intended for healthcare professionals

Editorials

The role of the routine neonatal examination

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7184.619 (Published 06 March 1999) Cite this as: BMJ 1999;318:619

It has many aims, few of them evaluated

  1. D M B Hall, Professor of community paediatrics
  1. Division of Child Health, Sheffield Children's Hospital, Sheffield S10 2TH

    Papers p 627

    Mothers meticulously inspect their newborn infants,1 but, because health professionals think they can do it better, routine neonatal examination is universally accepted as good practice.2 Is this really useful and, if it is, should infants be examined twice or is once enough? No one has yet been brave enough to address the first question with a randomised trial. As to the second, common sense suggests that a second examination might occasionally detect a problem missed at the first one, but a study from Aberdeen now tells us firmly that one is sufficient (p 627).3 If there are any benefits from a second examination, they were too small to be detected in a sample of 10 000 babies, though the study lacked the power confidently to compare outcomes for congenital dislocation of the hip and serious heart disease.

    Medical staff shortages often delay discharge after childbirth until the baby can be examined. The examination is usually done by junior doctors and is of uncertain quality. Thus there is increasing interest in midwives or health visitors doing this job—but nurses insist on adequate training. The need to design a training programme is a powerful stimulus to revisit the rationale of traditional activities. So what is the evidence in support of routine neonatal examination?

    Some important anomalies are detected antenatally; some are associated with low birth weight, intrauterine growth retardation, or neonatal illness; and many are apparent at birth or are noticed within a few hours by the mother. In all these situations the paediatrician's job is to communicate the diagnosis with sensitivity4 and explain and plan management.

    Routine neonatal examination of babies whose mothers believe them to be normal aims to detect abnormalities that might be missed and, when none are found, to provide reassurance. Both the examination and its individual components are, therefore, a form of screening and can be evaluated as such. Other possible benefits from this procedure are harder to evaluate but may be just as important. They include providing information and education, recognising and supporting parents with mental health problems, and preventing postnatal depression.5

    What are the target conditions and can they be reliably detected? The list is long, but few meet the classic criteria for a screening test. How and with what confidence can normality be recognised? The experienced observer first carries out a “gestalt” inspection,6 looking for evidence of dysmorphic syndromes, atypical behavioural patterns, and signs of acute illness such as impaired alertness or respiratory problems. Normal patterns of responsiveness and movement are reassuring, but transient and non-significant abnormalities limit the specificity of neurological examination.7 Systematic examination may reveal various common abnormalities, which are usually not important but worry parents. Examples include minor birth injuries such as cephalhaematoma, fractured clavicle, haemangioma, preauricular tags, and erythema toxicum. Some anomalies must be sought with more care, such as congenital cataract and other eye defects, submucous cleft palate, hypospadias, and cutaneous markers of occult spinal dysraphism.

    Much of the anxiety expressed by many general practitioners about examining newborn infants is focused on two conditions, heart disease 6 8 and congenital dislocation of the hips. The Aberdeen group, like many others, noted that several cases of hip dislocation were missed. Screening for congenital dislocation of the hip is still problematic9—and primary screening by ultrasound is not the answer. The clinical examination may be too difficult for a screening test, or intrinsically flawed, but personal observation of examination candidates suggests that poor technique due to inadequate training is at least partly to blame.

    The most serious forms of congenital heart disease usually present within the first few days and demand prompt investigation. The concern is about missing defects that might present after the baby leaves hospital and have rapidly progressive symptoms. Unfortunately, even the most expert examiner will miss many cases since some conditions are not detectable in the early days of life, before the ductus closes. Perhaps greater awareness among parents and the primary care team about the need to take non-specific symptoms seriously would be a better way of identifying these babies.

    Many other conditions, notably some metabolic, hepatic, and neurological disorders, evolve over the early weeks of life and are not readily detected on the first day.10 It is therefore important to redefine the role and timing of the neonatal examination and the part played by different health professionals. A midwife trained in neonatal examination could do the initial assessment and also ensure that screening programmes are properly explained 11 12 and could monitor the neonate's progress during routine visits to the mother.

    If detection of dislocated hips and heart disease are regarded as key outcome measures, robust comparisons between different approaches to the neonatal examination need enormous sample sizes. It may be more profitable to compare clinical competence and skill acquisition between professional groups and to evaluate other less tangible outcomes such as the quality of information provided and parental satisfaction.

    References

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