EDITOR—As a senior house officer in a neonatal unit with over 7000 births a year, I can confirm Hall's remarks that needless delays in the discharge of mothers and their babies occur due to heavy workload.1 My crude, hurriedly acquired examination skills often act as a front and do little to reassure me that all is well with the child I am examining. Inquiries about feeding, the behaviour of the child, and even the contents of the child's nappies give me greatest confidence in my clinical decision making.

Most valuable time during neonatal checks is spent talking about educational aspects of child care and what a new mother can expect from her child in the coming weeks. I believe that medical examination can be carried out by a midwife, with positive advantages for mother and child. The established relationship between midwife, mother, and child should be built on to create a seamless flow of reassuring advice; the clinical examination would be seen as part of that process and not a separate issue. Where high sensitivity and specificity exist for parts of the clinical examination, protocols should continue to be used to ensure correct management.

Having witnessed the successful contribution made by advanced neonatal nurse practitioners in the unit in which I work, I believe that clinical examination skills, if properly taught, can be undertaken by other medical staff; doctors should not regard this as a challenge to their position. If neonatal examination is recognised as a blunt tool in the screening for childhood diseases then we should not be afraid to redefine our goals and alter our clinical practice to ensure a better quality of care and education.

EDITOR—Hall1 concluded from the paper by Glazener et al2 that having two routine neonatal examinations is no better than having one. Three issues must be considered.

Firstly, the conclusion was partly based on Glazener et al's findings that, although more babies who were examined twice attended orthopaedic outpatient clinics for suspected congenital dislocation of the hip, there was no significant difference in the number of babies who required active management.2 In both groups, however, the number requiring active management was small (12 v 15), and the study was unlikely to have sufficient power to detect differences in the outcome between the two groups even if they existed.

Secondly, dysplastic hips which were detected early might have been managed satisfactorily by measures such as double nappies, hence reducing the number of babies requiring active management.

Thirdly, in many countries neonatal examination provides the only opportunity for a paediatrician to detect abnormalities that might otherwise be missed by a general practitioner. Hence a second examination minimises the risk of an important diagnosis being missed.

Applying traditional criteria for good screening tests, Hall also doubted whether neonatal examinations are really useful. But such examinations are different from many screening tests.

Firstly, most parents like to receive either counselling on minor problems or reassurance that their newborn babies are normal. Since the health professionals must examine the baby before such explanations or reassurance can be given and the time taken to perform a proper neonatal examination is probably no more than five minutes, abolishing routine neonatal examinations is unlikely to save much time.

Secondly, neonatal examination may occasionally detect initially unsuspected serious conditions, prompt treatment of which may greatly improve prognosis.

Thirdly, apparently minor abnormalities may indicate serious underlying abnormalities. These may prompt active treatment or close monitoring for the development of complications.

The role of neonatal screening should be evaluated using broader criteria than Wilson and Jungner's criteria for screening.3 Much stronger evidence is required to convince the public that an existing neonatal examination programme should be withdrawn than to convince them that a new screening programme should be introduced. The decision to abolish neonatal examinations cannot be taken lightly.