Nottingham Neonatal Service – Clinical Guidelines
Title of Guideline (must include the word “Guideline” (not
protocol, policy, procedure etc)
Guideline No. A11
Newborn Infant Physical
Examination (A11)
Author: Contact Name and Job Title
Dr Stephen Wardle (Consultant
Neonatologist)
Angie Godfrey (Midwife/Antenatal
Screening Co-ordinator)
Emma Haworth (Midwife/Antenatal
Screening Co-ordinator)
Directorate & Speciality
Neonatal Intensive Care Unit, Delivery
Suite, Postnatal Wards
Family Health
Date of submission
May 2017
Explicit definition of patient group to which it applies (e.g.
inclusion and exclusion criteria, diagnosis)
Version
If this version supersedes another clinical guideline please be
explicit about which guideline it replaces including version
number.
Statement of the evidence base of the guideline – has the
guideline been peer reviewed by colleagues?
All newborn infants cared for by Nottingham
University Hospitals NHS Trust, including
community who fit the inclusion criteria of
the guideline below.
4
3
1 Report of National Screening
Committee
Evidence base: (1-6)
1
NICE Guidance, Royal College Guideline, SIGN
(please state which source).
2a
meta analysis of randomised controlled trials
2b
at least one randomised controlled trial
3a
at least one well-designed controlled study without
randomisation
3b
at least one other type of well-designed quasiexperimental study
4
well –designed non-experimental descriptive
studies (ie comparative / correlation and case
studies)
5
expert committee reports or opinions and / or
clinical experiences of respected authorities
6
recommended best practise based on the clinical
experience of the guideline developer
Consultation Process
Nottingham Neonatal Service Staff and
Clinical Guideline Meeting, Midwifery
Services, Newborn Infant Physical
Examination Project Group
Ratified by:
Date:
Nottingham Neonatal Service Staff and
Neonatal Task & Finish Guideline group.
February 2017
Target audience
Staff of the Nottingham Neonatal
Service, Delivery Suites and Postnatal
Wards, Community Midwives and
General Practitioners
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Nottingham Neonatal Service – Clinical Guidelines
Review Date: (to be applied by the Integrated Governance
Team)
Guideline No. A11
November 2020
A review date of 5 years will be applied by the Trust.
Directorates can choose to apply a shorter review date,
however this must be managed through Directorate
Governance processes.
This guideline has been registered with the trust. However, clinical guidelines are guidelines only.
The interpretation and application of clinical guidelines will remain the responsibility of the
individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using
guidelines after the review date.
Introduction
The midwife performs a basic physical examination of the newborn to detect gross abnormality
which is performed shortly after birth. This guideline is concerned with the performance of the
more thorough Newborn Infant Physical Examination (NIPE) which must be performed within 72
hours of birth by a qualified Practitioner. The guideline provides information to all practitioners as
to the correct procedure to follow when performing the newborn examination, thus, providing an
appropriate neonatal assessment aiming to reduce the risk of neonatal mortality and morbidity.
The UK National screening Committee has produced standards and competencies for the NIPE
programme which form the basis of this guideline and the post natal protocols.
Parents should be offered two full physical examinations of their newborn. Following the initial
examination within 72 hours, the second examination should be carried out when the baby is 6-8
weeks old by the GP and documented on the SMART IT system.
The purpose of the examination of the newborn is;
 to screen for abnormalities,
 to make referrals for further tests or treatment as appropriate
 to provide reassurance to the parents.
The NIPE is a systematic examination of the newborn and is an integral part of child health
surveillance as defined in National Framework for Children, Young people and Maternity (DOH
2007) and is included in the NICE guidelines for postnatal care (2006)
Initial Examination at Birth (responsibility of the Midwife at birth)
Obviously, parents will want to know the sex of their baby, their birth weight and whether there
are any major anomalies immediately after the birth. For normal deliveries the midwife
undertakes this and reassures the parents that the baby appears healthy. The following features
should be checked at birth:








Face (observe for any features of Down syndrome / abnormal features).
Back (to exclude spina bifida).
Genitalia (to exclude ambiguity).
Gross anomalies of trunk or limbs.
Palmer creases
Evidence of birth trauma, bruises, scalpel marks etc
Check temperature
Anus (for patency)
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Guideline No. A11
The Apgar score, birthweight and head circumference are also recorded, with the number of cord
vessels.
If polyhydramnios was present, a nasogastric tube should be passed by the qualified practitioner
to exclude oesophageal atresia.
If the baby required difficult resuscitation then the heart and lungs are carefully examined by the
neonatal team, but if the baby is pink and breathing comfortably these parts of the examination
are best left until later, as are the checking of the hips and the neurological assessment.
Consent
 Prior to the NIPE, consent should be obtained from the parents. Parents should have
received the National Screening Committee leaflet ‘Screening tests for you and your
baby’ in the antenatal period. If the woman has not read the information booklet she must
be given a copy to read before to the examination

Knowledge and understanding of NIPE should be confirmed immediately prior to the
examination. Translation services should be utilised for anyone whose first language is
not English

If parents decline the NIPE examination this must be documented on the NIPE SMART
computer system and in the PCHR .The decline must be flagged on the electronic
discharge and review recommended by the GP, Community Midwife and Health Visitor.

If parents decline a referral following identification of an anomaly i.e hips, this must be
documented as above to ensure the GP, Community midwife and Health Visitor are
informed.
Timing of the NIPE

The examination should be undertaken within 72 hrs in line with programme standards.
NIPE trained practitioners can access a list of babies born and requiring an examination
at each campus by logging into the NIPE SMART system, this highlights babies over 48
hours old in amber, and those who are over 72 hours of age are highlighted red .
(See NIPE SMART SOP IN APPENDIX 2)

There is no lower time limit for when the NIPE examination can be performed.

NIPE examination in hospital is a priority before discharge to avoid the risk of a late or
missed examination in the community.

It is the parental right to discharge their baby from the hospital without a full neonatal
examination. In such cases the midwife or doctor discharging the baby must ensure that
the parents are given a letter to go to the community midwife asking him / her to perform
the newborn check with a copy to the GP. Discharge documentation must include a clear
statement indicating that the NIPE needs to be completed. For any babies discharged
home to cross border areas or transferred to another unit, contact a NIPE SMART super
user to use the transfer out facility on NIPE SMART.

The timing of the examination will be further determined by the time of birth, (it therefore
needs to be recorded on the work list for the day), availability of a trained professional
and parents’ wishes.
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Guideline No. A11

In addition to the daily NIPE clinic’s, the availability of a NIPE qualified midwife to perform
the examination can be identified on the E-Roster (e.g. Evenings and overnight) to
ensure every effort to complete the NIPE is made prior to discharge.

False positives due to early examination may be identified , however the benefits of an
early hospital NIPE exam outweigh the risks of a delayed / omitted examination in
the community
NB There are a number of reasons why ideally delaying the definitive examination from
the period immediately after birth to 24 hours of age may be beneficial:1. Cardiac murmurs, usually from the ductus arteriosus or the foramen ovale which have
not immediately closed, are often present soon after birth.
2. Auscultation of the lung fields often reveals crackles due to lung fluid which has not
yet been reabsorbed.
3. The infant may be a little hypotonic or jittery and will handle much more normally later
and therefore be easier to assess.
4. The newborn easily gets cold when wet with amniotic fluid immediately after birth, and
should not be exposed to a lengthy examination.
5. The mother is tired and wants to cuddle her baby and rest, without undue disturbance.
6. Anxieties about passing stool and urine as well as establishing feeding can be
addressed.
Roles and Responsibilities
Examination of the newborn can be performed by appropriately trained professionals including:
 a midwife
 an Advanced Neonatal Nurse Practitioner
 a neonatal doctor.
 a GP

It is the responsibility of the midwife to ensure that babies in their care are offered NIPE
as recommended by the NSC. The midwife must liaise with the neonatologist / NIPE
midwife to identify and prioritise babies requiring NIPE according to babies age, length of
stay / discharge requirements.
 NIPE trained practitioners can access a list of babies born at each campus by logging
into the NIPE SMART system, this highlights babies over 48 hours old in amber, and
those who are over 72 hours of age are highlighted amber.
(See SMART SOP IN APPENDIX 2)
Trained midwives can undertake NIPE on any term, well baby. The following exclusion criteria
apply:
Exclusion Criteria:
 Pre natal or post-natal diagnosis of Chromosomal abnormalities Baby who has been on
NICU for more than 24 hours
 Dysmorphic features have been identified following birth
 Suspected antenatal abnormalities other than mild renal pelvic dilatation
 Previous unexplained neonatal death (NND)
 Babies going for adoption
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The following factors must also be considered (but are not contra-indications to midwife
NIPE):
 Babies whose mother has Group B-haemolytic strep (GBS) or prolonged rupture of
membranes (PROM) – follow the infants at risk of neonatal infection guideline (Neonatal
Guideline C6 Dilated renal pelvices – follow the referral pathway (see table)
 Previous child with dislocated hips or if this baby is Breech – follow the Congenital
Dislocation of Hip Guideline (Neonatal Guideline F9).
 Meconium stained liquor
 Poor APGARs or low cord pH (10 min Apgar <=5 or cord pH < 7.0)
The neonatal team should always be informed of any babies with abnormalities and follow the
appropriate guidelines as above.
In particular, it is important that if there are practices or procedures with which you are
unfamiliar that you should not only refer to guidelines but also ask for help if necessary.
Senior assistance is always available.
There are guidelines for most common postnatal ward problems. We all work best as a team. In
the first instance, please ask the low / transitional care SpR for the day if you are unsure about
a matter or need help. They can be contacted via the Neonatal Unit. If they are unavailable,
speak to the Neonatal Service Registrar.
Procedure for the Newborn Examination
 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).

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 baby. Alcohol gel must dry completely
before handling.

The aims and limitations of the examination should fully explained

Obtain maternal history regarding pregnancy, date, time and type of birth and any
complications / problems or high risk antenatal screening results referring to maternal
Part 1, hospital notes, birth summary and Maternity Medway alerts in Summary of Key
Indicators on Medway (paediatric alerts).

Obtain verbal parental consent for examination of her baby.

Obtain family history and particularly any sibling history. In particular, ask about family
history of hearing problems or hip dislocation / childhood heart problems / eye
abnormalities e.g. childhood onset, cataracts, retinoblastoma or glaucoma

Identify risk factors for TB; family history / ethnicity and advise parents accordingly. Make
arrangements for BCG administration. (see Neonatal Guideline C4 BCG Vaccination)

Identify risk factor of Hepatitis B positive mothers and ensure relevant vaccination
programme is commenced (see Neonatal Guideline C7 Hep B)
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Nottingham Neonatal Service – Clinical Guidelines
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
Discuss with mother how she perceives the baby is progressing e.g. feeding pattern,
sleep pattern, urination and passing of meconium.

Ensure she has been given a parent held Child Health Record (red book) – check she
understands how this is used.

Ensure that all mothers under 16 years of age and others with family problems are known
to the social work team (discuss with the midwifery team first). Whilst it is not routine
practice to refer all pregnant teenagers under 16years of age to social careit is important
to consider this. Under 13 year olds are all referred to social care and those where there
are concerns relating to the safeguarding of them and or the unborn. It is very important
to be aware of all babies born into families where there are safeguarding concerns, what
the concerns are and how the risks have been mitigated / managed.
On completion of NIPE
 The results should be shared with parents and documented on the NIPE SMART IT
system

Print 3 copies of the summary from SMART and file as follows;
- attach two copies to page 3 of the personal Child Health Record (PCHR Red book).
- File one copy (including body map from red book) in the maternal notes
following the delivery summary page.
NB- If the baby has a set of notes print and file a fourth copy within them.

Page 4 of the PCHR should be fully completed and the pink copy removed and filed in
maternal notes with the copy of the summary and body map.

The reason for any referral and approximate timescale for an appointment should be
given to parents and all referrals made must be clearly documented.
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Guideline No. A11
5.1 Undertake a systematic NIPE examination of the following: Encourage the parents to ask questions during the check and to participate where appropriate (e.g. for a mother with her first baby, feeling the
fontanelle with the reassurance that it is normal)
The optimal way to perform the newborn check is by examining from “head to toe” sequentially. This should include general condition and
appearance including colour, breathing, behavior, activity and posture.
The hip check should be performed at the end of the examination.
The examination order has been presented below as it appears on NIPE SMART IT system for consistency The items to be examined are
summarised along with the referral pathways from hospital or in community:
ANATOMICAL
FEATURE
OBSERVATIONS TO BE MADE / POINTS TO BE NOTED see appendix for
expanded descriptions
REFERRAL PATHWAY
Hospital and Community
For non-urgent problems unless
otherwise specified write a referral
letter to a neonatal consultant
clinic for a non-urgent
appointment.
Consider craniosynostosis, see below
HEAD
CIRCUMFERENCE
HEAD AND
SKULL
Anterior Fontanelle- Size, tension
Cranial sutures- Closely applied, or widely separated or normal.
Be aware of craniosynostosis – premature fusion of sutures
Scalp- Moulding, caput, bruising, forceps marks, cephalhaematoma or scalp electrode
damage
See below
In hospital- if craniosynostosis is
suspected contact the registrar or
consultant to review. See appendix.
For clinic follow up use the generic
letter template on NIPE SMART for a
follow up appointment and send
according to instructions on the letter.
In community- telephone the
neonatal secretaries (and write a
referral letter) and request an urgent
neonatal outpatient review
TONE
Passive tone: put each of the 4 limbs through a full range of passive movements.
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Nottingham Neonatal Service – Clinical Guidelines
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Active tone: traction to sitting position - look at neck and arm flexors; ventral
suspension - head up to horizontal briefly
REFLEXES
Grasp, sucking, rooting, stepping, placing, Moro
SKIN
Pale, blue, jaundice.
Facial birthmarks - Salmon patch. Port wine stain. Mongolian blue spot birth marks ,
dry abrasions,bruises, cannula marks. Document on Red Book body map
Jaundice – see jaundice guideline
Cyanosis – needs urgent referral to
neonatal (hospital) or paediatric
registrar (community)
Port wine stains in the facial /
temporal region should be referred
for non-urgent neonatal outpatient
review
FACE
Appearance, asymmetry, trauma- document on Red Book body map
Nose- Patency of nasal passages (pass feeding tube if in doubt).
EARS
Normal pinna, skin tags, no accessory auricles. Use auroscope if any dysmorphic
features externally.
For referral to plastics use the NIPE
SMART standard letter template and
follow instructions on the letter to email or fax.
Facial nerve palsy should be referred
to neonatal registrar (hospital for
review) or for non-urgent review in a
neonatal follow up clinic See
appendix
In hospital and community - if
concerned about accessory auricles
refer to consultant clinic using the
generic clinic form and give to
receptionist/put in ward diary Do not
advise ‘tying off’
Hearing
All infants should undergo a newborn hearing screening test prior to leaving hospital,
any referrals for hearing will be organized by the hearing screening service ext 62798.
The hearing screeners need the red book to file their carbonated pages.
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Nottingham Neonatal Service – Clinical Guidelines
Guideline No. A11
In community parents are given information on drop in clinics for screening. Any
referrals are made by them if required.
MOUTH AND
PALATE
Clefts of hard or soft palate (look and palpate)
All babies with identified cleft lip or
palate will have had contact with the
Cleft Lip and Palate Team by phone
0115 9249924 ext 62886. See
appendix
In hospital the cleft nurse will assess
for feeding. If there are problems,
baby may be referred to D34 as an
inpatient for feeding assistance.
Tongue and gums
Cysts, loose supernumerary teeth
which will need removing
In community if there are concerns
telephone the on call registrar via
switchboard at the QMC.
NECK AND
CLAVICLES
LUNGS
Abnormally short, or webbed, cysts, sinuses, swellings.
Fracture, mobility
Clear lung fields. Breath sounds. Respiratory distress
Refer to Guideline: Indications for admission to the Neonatal Intensive Care (Neonatal
Guideline A2)
In hospital any baby with signs of
respiratory distress (RDS) should be
reviewed by the neonatal SHO for the
wards.
In the first 4hours if they are centrally
cyanosed or grunting, or tachyapnoic,
or has chest recession they should
be admitted to neonatal unit for
assessment. If concerned do not wait
4 hours.
In community midwives must always
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Nottingham Neonatal Service – Clinical Guidelines
Guideline No. A11
discuss baby with on call paediatric
registrar and ask for review in ED.
CHEST
Size and shape and nipples
ABDOMEN
No distension. Liver not more than 2 cm. below the costal margin, spleen not palpable,
kidneys only felt on deep bimanual palpation, bladder not palpable
In hospital if any organs are
palpable have the baby reviewed by
the registrar.
Inguinal hernias will require surgical
review and repair; contact the
Paediatric Surgical Registrar at QMC
via switchboard. Complete generic
clinic referral form to raise an
appointment.
13 - UMBILICUS
14 - GENITALIA
Smell, discharge, hernia
Ambiguous
Male:(see below for testes), normal prepuce (excludes hypospadias). Normal urinary
stream (should be passed by 24 hrs) - dribbling implies posterior urethral
valves.Hydroceles – no action needed, if still present at 12 months advise parents to
discuss with GP.
Female: Normal labia (not fused) and clitoris normal in size. White vaginal discharge is
normal due to maternal oestrogens (may become pink on about 4th day)
st
Routine appts 1 reassurance
Hypospadias repairs – reassurance initial
Surgery over a year
Routine outpatient
Umbilical hernias are not significant
no action is needed.
Urgent referral to neonatal registrar
(see Neonatal Guideline Disorders of
Sex Development (F7)).
For hypospadias: Use the Urology
referral form and give to the ward
receptionist/put in ward diary to send
to Paediatric Urology Dept, QMC, E
Floor, East Block.
If urgent referral telephone secretary
and send referral form via fax
9709419.
In community bleep the paediatric
registrar on call via QMC switchboard
and request urgent review.
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Nottingham Neonatal Service – Clinical Guidelines
ANUS
UPPER LIMBS
Guideline No. A11
Patent, position, meconium should be passed within 24 hours.
If meconium not passed within 24 hours:
Equal in size and length. Fingers normal. Two palmar creases on each hand. Brachial
pulses.
Polydactyly should be referred as soon as possible to plastic surgery.
Erbs Palsy
In hospital- refer to registrar.
In community- bleep the paediatric
registrar on call via QMC switchboard
and request urgent review..
In hospital- refer to paediatric plastic
surgery at QMC by using the
standard letter template on NIPE
SMART and either e-mail or fax
according to instructions on the letter.
In community as above
In hospital Inform consultant during
hospital stay for review. All should
have a follow up appointment made
to the on service neonatal consultant
clinic at 2 weeks of age, use the
generic clinic referral form and give
to ward receptionist / put in ward
diary.
In community- telephone the QMC
on call neonatal registrar via switch
incase need ED.
BACK AND SPINE
LOWER LIMBS
Any scoliosis. Any hair tufts, naevus or abnormal skin patches. Any birth marks. Any
sacral pits – see further guidance appendix 1.
Equal in size and length. Tone, movement, Femoral pulses. Oedema, digits
In hospital, if any abnormality of the
sacral dimple is noted refer to the
neonatal registrar for review. See
appendix
In community refer to neonatal
consultant clinic for non-urgent
review
In hospital discuss with neonatal
registrar. See appendix for
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Nottingham Neonatal Service – Clinical Guidelines
AND FEET
Guideline No. A11
Hyper extensile / disclocatable / dislocated knees.
Ankle defomities - Talipes. Check that the deformity can be fully corrected by gentle
manipulation - refer if not. Be aware that there is an association with DDH and Talipes
so pay careful attention to hip examination.
guidance.
For urgent appointment telephone
the paediatric orthopaedic secretaries
on any of these extensions 63666 /
63244 / 63141.
In hospital Prenatal diagnosis of
talipes parents will have received
contact from Mr Hunter’s secretary.
In community contact the QMC on
call registrar via switch and request
an ED appointment.
Talipes: for an urgent appointment
telephone the paediatric orthopaedic
secretaries: Mr Lawniczak (63244),
Mr Chell (63141) or Mr Hunter
(63666). If baby is on NNU they will
visit there. Also send follow up FAX
9194405
In community fill in (insert name)
referral form, or telephone
secretaries for an urgent
appointment, see details above.
Positional Talipes and Talipes
calcaneo-valgus order appointment
on NOTIS: THERAP or
telephone paediatric physiotherapists
at QMC 65326.
Polydactyly: refer to plastic surgeons
via NIPE SMART referral form
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Nottingham Neonatal Service – Clinical Guidelines
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Normal heart sounds and no murmurs. Rate, rhythm
HEART
If murmur heard look for other signs and symptoms of congenital heart disease,
include palpation of femoral pulses.
In hospital If a murmur is heard
keep baby in until over 24hours old
and re-examine. If murmur persists
ask neonatal registrar to review. See
appendix
If the murmur is not heard on review,
can discharge home and ensure the
newborn examination workflow in
NIPE SMART is updated.
If murmur is still heard with no
concerning features, can discharge
home and refer to Neonatal
Consultant outpatient Clinic using
cardiac referral letter template on
NIPE SMART Fill in as much as you
can and e-mail / fax according to
instructions on the form
In community, bleep the paediatric
registrar on call via QMC switchboard
and request review.
HIPS
Ortolani’s test and Barlow’s test to detect dislocated and unstable hips
The following babies should all be referred to the hip clinic:
Breech since 36 weeks
babies with clicky hips
any instability – urgent referral within 14 days
family history of first degree relative
QMC Clinics
Urgent Appointments Tuesday afternoon
Routine Appointments Friday afternoon
In hospital and community,
complete the standard Hip referral
letter template on NIPE SMART as
fully as you can and either e-mail or
fax according to the instructions on
the letter. See appendix
Central Appointments FAX
01158754613
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Nottingham Neonatal Service – Clinical Guidelines
EYES
Guideline No. A11
Position and size. Normal clear black pupils (no cataracts) with normal red reflex.
Subconjunctival haemorrhages (dramatic but harmless). Document on Red Book Body
Map
TESTES
Both testes in scrotum
In hospital and communitycomplete the standard eye referral
letter template in NIPE SMART IT
system and either e-mail or fax
according to the instructions on the
letter. See appendix
If no red reflex ask neonatal registrar
to review. In community request
urgent neonatal outpatient clinic
appointment via neonatal secretaries.
If retractile/incompletely descended
ensure GP review at 6weeks.
In Hospital If both testes are not
palpable ask for Registrar review
whilst in hospital.
See appendix for guidance
If both undescended refer for routine
appointment for reassurance to
paediatric surgeons: Mr Williams
(62626), Mr Shenoy (62626) or Mrs N
Fraser (62615), surgery not done
until 12months old. NIPE SMART
standard letter template
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Nottingham Neonatal Service – Clinical Guidelines
Maternal
Thyroid
disease
Guideline No. A11
Maternal Graves’ Disease (or history of past
Graves) Thyrotoxicosis:
If TRAB >=1.0 IU take TFT sample at 4 days of age
make follow up appointment at 10 days old in clinic
using generic clinic referral form and leaving for
receptionists.
If TRAB <1.0 IU no further action required.
Hypothyroidism, no problems unless secondary to
previous immune thyrotoxicosis, if this is the case
follow as above.
See appendix for guidance
In community refer to neonatal outpatient clinic via
secretaries
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Ensure that the baby’s weight and head circumference are recorded and check on a weight chart
whether the baby is small for dates (<10th centile), appropriate weight for dates (10th-90th
centile) or large for dates (>90th centile).
The written notes should always include a statement about the baby’s hip examination, cardiac
findings and femoral pulses. All notes added to the NIPE SMART IT system will appear on the
printed documents.
Newborn Screening by blood spot is performed at 5 days (leaflets for parents are available on
postnatal wards).
Documentation
Record all findings onto the NIPE SMART computer system and print two copies to insert into
the CHR Record any anomalies detected and any subsequent action or referral made.
Where anomaly is identified complete a congenital anomalies register (CAR) audit sheet and
post to the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS)
National to the following address
c/o Mrs Gillian Gull, Registration Manager
National Cancer Registration Service (East Midlands)
5 Old Fulwood Road
Sheffield
S10 3TG
 Inform parent(s) of findings, and actions to be taken.
 Notify Neonatal SHO or Registrar of concerns and/or abnormalities found.
 Complete the ‘body map’ in the relevant page of the CHR / red book to document any
bruises, birth marks or skin lesions present and file the white sheet in the maternal (or
baby if generated) notes. This is important as sometimes infants may present later with
skin lesions which may be mistaken for bruising due to non-accidental injury if not
previously documented.
 In the community send the blue copy to the data clerks at the relevant hospital ensuring
the mothers name is on it so that the sheet can be filed in the mother’s records.
 NIPE performed by a midwife in the community or the GP must be recorded on system
one where available and CHR pages completed. Midwives must also record the
examination on NIPE SMART
REFERRALS
 When an abnormality is found then a prompt referral for medical investigation, treatment
or care must be made and documented on NIPE SMART.
 Parents should be aware of the likely timescale for the appointment if the appointment
cannot be made prior to the babies discharge.
 Parents should also know who to contact when a referral appointment if it is not
subsequently received as planned
EDUCATION AND TRAINING
Staff Training
 Staff will be provided training on Examination of the Newborn in line with the Nottingham
University Hospital Maternity Services Training Needs Analysis (2010) and as per
National screening Committee standards.
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 NIPE qualified staff will be trained to enter the examination onto the nation NIPE SMART
IT system, and provided a username upon training. Midwives are required completing the
approved NIPE qualification.
 Neonatologists / paediatricians- receive training at the point of induction
 General Practitioners Complete initial training,
It is mandatory for all health professionals performing the NIPE examination to annually complete
the National Screening Committee on line e-learning resource via the following link;
http://cpd.screening.nhs.uk/nipe-elearning
 . Each individual must evidence this at their yearly appraisal.
Monitoring and compliance
The antenatal and Newborn Screening coordinators are required to report the following Key
Performance indicators on a quarterly basis i.e. quarter 1 April to June
UK NSC Key Performance Indicators NHS Screening, Antenatal, newborn, young person
and adult, Year 2015-16 Version 2.0 Date: 20 March 2015

KPI NP1: Newborn and Infant Physical Examination – coverage (newborn)
Description The proportion of babies eligible for the Newborn physical examination who
were tested within 72 hours of birth
Performance thresholds Acceptable level: ≥ 95.0%
Achievable level: ≥ 99.5%

KPI NP2: Newborn and Infant Physical Examination – timely assessment of DDH
Description The proportion of babies who, as a result of possible abnormality of the hips
being detected at the newborn physical examination, undergo assessment by ultrasound within
two weeks of birth
Performance thresholds Acceptable level: ≥ 95.0%
Achievable level: 100.0%
A report will be run on a Monthly basis from NIPE SMART in order to audit the number of babies
discharged without having NIPE performed and to ensure it has been performed in the community
within 72hrs as per NSC standards. Findings will be disseminated as required to inform trust
screening quality group / NIPE project group / governance / screening programme board, and to
identify and manage operational issues.
Audit will be undertaken on a monthly basis within the community to ensure all NIPE examinations
performed by GP / Community midwives are documented on System one computer system
An annual audit will be undertaken of all midwives and doctors within the NUH Trust to monitor
completion of the online eLearning module.
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APPENDIX 1
Common Postnatal Problems
This is a brief outline of common problems you will encounter in the postnatal period. Please
keep it with you so you can refer to it as needed.
Postnatal wards also hold copies of:

NIPE SMART standard letter templates in case of IT system failure including;
Hip referral letter
Paediatric Cardiology referral letter
Referral of a Newborn with a murmur letter Neonatal eye referral letter
Undescended testes letter
Newborn screening Plastics referral letter
Antenatally detected urinary tract abnormality referral letter
Specialist immunisation coordination letter GP letter Hepatits B vaccination
Hepatitis B vaccination parent information letter
Hyperthyroid parent information letter
Newborn Screening Generic results letter

heart murmur parent information sheet

urology referral forms

‘neonatal’ continuation sheets (do not write on the mother’s obstetric continuation pages)
Other common problems
a. Heart murmurs
These are common in the newborn examination. Look for other signs and symptoms of
congenital heart disease (including palpation of femoral pulses). All murmurs will require the
Neonatal Registrar to review prior to discharge. If you are concerned about the baby, urgent
review should be sought. Otherwise, the baby’s details should be passed onto the Neonatal
Registrar with the approximate time or date of planned discharge to enable baby to be reviewed
at the most appropriate time. If the murmur is still present at review, with no concerning features,
the baby will be referred to the on-service Neonatal Consultant’s outpatient clinic for an
appointment in 14-28 days time. This is done via the cardiac referral form found on the postnatal
ward (PNW).
If a heart murmur is discovered by the community midwife they must bleep the paediatric
registrar and request that the baby be reviewed.
b. Respiratory problems
Any baby with signs of respiratory distress should be reviewed by the Neonatal SHO. If the baby
has any 2 of the following signs or is centrally cyanosed in the first 4 hours of life he / she should
be admitted to the neonatal unit for further investigation:
Grunting
Tachypnoea (>70 / min)
Recession
A single sign persisting or developing after 4 hours of age requires admission. See Neonatal
Guideline A3. If concerned do not wait until 4 hours of age for admission.
In addition any baby with stridor (audible noise on inspiration) should be reviewed by the
neonatal registrar.
c. Cleft Lip and Palate
All babies born with a cleft lip/or palate are referred to the Specialist Cleft Lip and Palate Team
by phone initially, to D34 0115 924 9924 ext 62886.
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All maternity wards have a written protocol to follow for these referrals. Babies born in the
community should be discussed with the neonatal registrar.
A nurse will visit the baby and mother and assess the cleft, give relevant and factual information
and discuss/demonstrate feeding.
All babies are seen by a Consultant Plastic Surgeon who will continue their care.
Ensure all babies with cleft lip and palate have their hearing test.
Any babies who are slow to establish feeding should be discussed with the appropriate Neonatal
Consultant, who may, in turn, wish to arrange their transfer to D34 for help with feeding from the
multidisciplinary team.
d. Ear tags / skin tags
If concern over appearance of any lesion, refer to plastic surgeons. Do not attempt to ‘tie off’ any
lesions.
e. Hernias
Inguinal hernias will require surgical review and repair; please contact the Paediatric Surgical
Registrar. Umbilical hernias are not important – no action is needed.
f. Undescended testes/hypospadias
Male: Check that both testes are in the scrotum. Testes in the inguinal canal are normal if they
can be induced gently into the scrotum.
If retractile / incompletely descended, ask GP to check at 6 weeks of age. Undescended testes
will require referral to a Paediatric Surgeon (Mr Williams or Mr Shenoy) as a non-urgent
outpatient. Midwives and SHOs should always refer the baby to the Neonatal Registrar if testes
are not palpable.
Beware a child with hypospadias and bilateral impalpable testicles – this may be a girl, thus
urgent assessment by a senior is required.
A child with hypospadias must not be circumcised prior to reconstruction surgery.
g. Hydroceles
No action needed. Advise parents to see their GP if they are still present at 12 months of age.
h. Infants at risk of hearing loss
All Nottingham babies undergo neonatal hearing screening. Neonatal hearing screening tests
are, however, particularly important for babies at risk of hearing loss, i.e.:
-
family history of congenital deafness/cleft palate
-
presence of a cleft palate
-
cared for on the neonatal intensive care unit for 48 hours or more
-
congenital CMV
Particular concerns can be highlighted by calling the neonatal hearing screening service 62798.
i. Abnormalities of Head Shape or Cranial Sutures:
It is very important to palpate the cranial sutures carefully and to assess the overall head shape
in order to rule out premature fusion of the sutures (known as craniostenosis). If this is not
detected early there is a risk that raised intracranial pressure will develop. This may lead to brain
damage. If you are unsure about the cranial sutures or head shape please ask an SpR or
consultant neonatologist to review the baby with you. Many heads are unusual due to moulding
at birth and will resolve in time but it is very important to detect true abnormalities early on. If in
doubt, early follow up in a Neonatal clinic is essential.
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Scaphocephaly is the most common abnormality and is caused by premature fusion of the
Sagittal suture. 80% of affected babies are males.
Clinical Presentation
Frontal bossing
Prominent occiput
Palpable keel ridge
OFC normal
Reduced biparietal diameter
Frontal plagiocephaly may be unilateral or bilateral
Unilateral
Flattened forehead on affected side
Flat cheeks
Nose deviation on normal side
Higher supraorbital margin
Bilateral
Broad flattened forehead
Hypoplasia of midface
Progressive proptosis
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Posterior Plagiocephaly is a common finding in infants after 2-3 months of age and is caused
by moulding of the skull. It is not pathological. If Posterior Plagiocephaly is present at birth it
is abnormal and may be due to premature fusion of the Lambdoid suture.
Unilateral
Flattening of occiput
Indentation along synostotic suture
Bulging of ipsilateral forehead leading to
rhomboid skull
Ipsilateral ear anterior and inferior
j.
Sacral dimples
Referral for a spinal ultrasound to Neuroradiology, and follow up in the appropriate neonatal
consultant clinic thereafter is indicated only if:
-
the dimple is not within the natal cleft
-
the dimple is not in the mid line
-
any other abnormality is present for e.g. a tuft of hair, skin discoloration, etc.
Babies with a sacral dimple that is within the natal cleft and is in the mid line do not require follow
up or investigation.
k. Orthopaedic problems
Club feet:
A club foot is a foot in which the heel is high (equinus) and somewhat tucked in
medially (varus). The forefoot is normally curved internally. The position of the foot cannot be,
or can only just be, corrected by manipulation. The details of cases of this should be telephoned
to the Paediatric Orthopaedic Secretaries on extensions 63666/63244, who will then allocate an
urgent appointment in the appropriate Consultant’s clinic. If a patient with clubfeet is going to be
an in-patient on the Neonatal Unit for a prolonged period then the orthopaedic team are happy
to come and see them on the ward. Please contact Mr Hunter’s Secretary for the Queen’s
Medical Centre (63666) and Mr Chell’s Secretary (63141).
In ‘positional talipes’ the appearance of the foot is similar, with a high heel and an inverted
forefoot. However, the position can easily be corrected to neutral and beyond. These cases
should be referred to the paediatric physiotherapists at QMC so that mother can be taught
stretching exercises (fill in green physio card, leave on ward – bleep paediatric physiotherapist).
Prenatal Diagnosis of Clubfoot Increasingly frequently clubfoot is diagnosed in utero although
antenatal ultrasound cannot distinguish between severe clubfoot and so called “positional
talipes”. Parents who have an ultrasound diagnosis of clubfoot are offered a standard letter
antenatally from a Consultant Orthopaedic Surgeon which lets parents know: “The treatment of
club foot depends on how flexible the feet are and how easy it is to put them into the correct
position. One cannot tell this until after the baby is born” and advising them to ask the midwifery
staff to call Mr Hunter’s secretary on Ext. 63666 to make an appointment. Parents are also
informed that “treatment [may involve] manipulating the feet into the best position possible and
holding them in plasters. If the feet do not correct, an operation is usually required at about 9
months of age.”
Talipes calcaneo-valgus:
In this condition the foot is dorsiflexed, often so severely that the
dorsum of the foot touches the anterior margin of the tibia. The heel is turned towards this. It is
caused by compression in utero and always responds to stretching. The child should be referred
to the paediatric physiotherapists at QMC so that parents can be taught appropriate stretching
exercises. There is an association between this condition and DDH so careful attention should
be paid to the hips of these children.
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Hyperextensile/dislocatable/dislocated knees: These are relatively uncommon, and true
dislocations of the knee occur only 1 in 100,000 live births. Cases such as these should be
telephoned to the Paediatric Orthopaedic Secretaries on extensions 63666/63244/63141, to be
given an appropriate appointment. Discussion with neonatal registrar is required.
Hip Instability Genuinely unstable hips must be seen at the Hip Instability Clinic within the first
14 days of life and, therefore, should be distinguished from clicky hips, positive family history etc
that need less urgent scanning.
The following babies will require referral to the Hip Clinic via the standard referral form.
-
All breech babies (whether born by vaginal birth or caesarean section)
-
All babies with clicky hips
-
All babies with unstable hips (urgently within 14 days)
-
Babies with a family history of an affected first degree relative.
Please refer to the Nottingham Guidelines for Screening of Developmental Dysplasia of the Hip
later in this guideline.
The on-call orthopaedic registrar should be contacted for emergencies only i.e. bone and joint
infections. They cannot make out patient appointments.
l.
Post axial (ulnar) polydactyly
Children with post axial (ulnar) polydactyly should be referred by telephone call to the Plastic
Surgery Registrar at the Nottingham City Hospital Campus as soon as polydactyly is discovered.
m.
Shoulder dystocia / Erb’s palsy
All babies with an Erb’s palsy must have an appointment made in the relevant neonatal
consultant clinic at 2 weeks of age. All severe palsies should be notified to the Neonatal
Consultant during the stay on the postnatal ward. Some babies will need either referral at birth
or subsequently to a tertiary surgical service.
At birth:
complete palsies, with or without Horner’s sign
< 1 week:
all neonates without active finger extension
1 month:
all children without some recovery of biceps
2 months:
all children without full biceps function
Shoulder dystocia / Erb’s palsy (continued)
All patients need to be referred to the paediatric physiotherapist prior to discharge who will
arrange their own follow-up. Babies born in the community should be discussed with the
neonatal registrar.
n. Management of infants born to mothers with ‘minor’ blood group antibodies (e.g. AntiKell/anti-Duffy, etc)
Cord blood should be sent for infant’s blood group and direct Coombs’ test. No other
investigations are needed unless infant appears jaundiced or anaemic. If Coombs’ test is
positive, but baby is asymptomatic, no further follow-up is needed.
If infant develops jaundice requiring treatment secondary to haemolytic disease, the infant should
be started on folic acid and seen in out-patients for an Hb in 2 – 4 weeks (depending on
discharge Hb). Make an appointment with the consultant neonatologist on service at the time of
discharge if baby not previously admitted to NICU.
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o. Maternal thyroid disease (see Neonatal Guideline F2)
Thyrotoxicosis
Maternal thyroid stimulating antibodies may cause transient neonatal thyrotoxicosis. These
infants will need TFTs checking on day 4 of age and follow-up with results in clinic at 10 days of
age (as per guideline).
Hypothyroidism
Maternal hypothyroidism does not cause neonatal problems – unless hypothyroidism is
secondary to previous immune thyrotoxicosis (where maternal stimulating antibodies may still be
present). All other infants do not require investigation and do not need follow-up.
p. Urinary tract abnormalities - see Neonatal Guideline F8. A clinically well baby with
unilateral urinary tract abnormality should have a standard referral letter completed as per the
guideline. These infants do not usually require further tests at this stage. Midwives can
complete these but should always refer to the Neonatal Registrar if unsure whether further
investigations are required.
Babies with bilateral abnormalities should be referred to the neonatal team.
Guidlienes can be found on the TRUST INTRANET SEE EXAMPLES BELOW

F9
Screening for hip dislocation (DDH)

F8
Guideline for antenatally diagnosed urinary tract problems

F7
Diagnosis of ambiguous genitalia

F2
Management of infants born to mothers with thyrotoxicosis

F1
Management of infants born to drug-abusing mothers

D16
Management of jaundice

D1
Management of infants at risk of hypoglycaemia
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APPENDIX 2
Maternity Standard Operating Procedure (SOP)
Subject
Owners
How to record and print a Newborn Infant Physical
Examination (NIPE) on SMART and MEDWAY
Effective Date
Alison Bradley, Vicky McCormick, Version
Angie Godfrey, Emma Haworth
7th April 2015
1.0
This procedure is to be followed each time a NIPE examination has been
completed
1. Log into MATERNITY MEDWAY and SYSTEM ONE in the community
2. To obtain maternal or paediatric alert and information;
In hospital view Medway Maternity and ask the parents
In community view Systmone booking entry for the maternal history, part 2
record and ask the parents
3. Access SMART – https://nipe.northgate.thirdparty.nhs.uk/nipe and log in
with user name and password, on the main menu click patients on the left
hand side.
3a NIPE Clinic setting - How to create the live work list
 Click new search
 In the DOB from box click ‘todays date’
 Set the newborn screening box to ‘ALL’
 Submit search criteria
 The live work list will appear click view on the appropriate baby
 Baby summary tab will appear click on Screening tab and follow
instructions –from number 6
4. Individual NIPE - To find a baby record click “New Search” in the left
column.
5. Enter NHS number, name or date of birth to search, click “submit search
criteria” or press enter on keyboard.
6. On the “Screening” page complete the ‘Risk Factor’, ‘Local Data’ and Screen
Results tabs only following the below instructions (no data is to be entered
into pulse oximetry tab).
7. Click the Risk Factors Tab
If the baby is on Neonatal unit click ‘NICU’ in the ‘Patient Group’ at the top left of
the tab
If consent to the exam is declined select ‘declined’ at the top right of the tab,
then save and print.
If there are no risk factors, set all to ‘NO’ by clicking ‘Set all ‘unknown’ risk
factors to ‘no’’ via the button at the top of the list .
If there are any risk factors click ‘Yes’ in the relevant sections, then click the
relevant notepad icon and add free text information .
Any notes entered will be printed onto baby notes and referral letters.
8. Click the Local Data tab to enter the top to toe examination. To see guidance
for each item in column 1 hover the cursor over the ? button.
9. Click ‘Set All to Normal’ button at the top on the right side.
Enter feeding method at the bottom of the list.
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Nottingham Neonatal Service – Clinical Guidelines
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If the examination is entirely normal click the screen results tab to move to
the next page.
Abnormality detected- click ‘Abnormality Suspected’ for the relevant item and
document in the ‘Comments/Action Taken’ Column
All responses and comments will be printed onto baby notes and letters.
10.Click the Screen Results Tab
Click ‘All Tests Done’ button at the top left of the page.
This indicates you have performed the whole NIPE.
Abnormality detected- complete the relevant line for ‘Hips’, ‘Testes’, ‘Eyes’,’
Heart’ and ‘Rest of physical examination’, and add comments by clicking on
the ‘Notes’ icon in the final column
If unable to complete the NIPE tick NO in the test done column of the
appropriate item not Completed, add notes and refer for senior review and
NIPE completion.
All data from this screen is printed onto the child’s red book page.
11.Click ‘Now’ button to Input the date and time of examination, OR input date
and time of examination manually if the data entry is retrospective
12.If a senior clinician is required to review any aspect of the examination, tick
‘required’ in the ‘review by senior clinician’ box at the bottom right of the
screen . Notes can be entered to explain your reason.
13.Click ‘Save’ at the bottom right of the screen only when you have finished
entering all data on this tab.
14. SMART -Printing Paper Work
On the results page click ‘Print All’.
A print list will then be populated which you will be taken to. This is a live
populated list so your print job may not be at the top of the list. Click on ‘Filter
by date’ button to show most recent jobs.
Find your baby.
Click on the word icon.
Click open – Do not need to save as it will always be available on the live
system.
The red book page and an A4 summary page (for filing) will be opened.
Print 2 sets of these pages
Staple both copies of Page 1 onto page 3 of the red book
Complete page 4 manually, tear out pink page and file in the maternal notes
Page 2 and any referral letter -file 1 copy in the maternal notes, 1 copy in the
baby notes, if generated.
Once printed close the word document without saving
REFERRAL LETTERS- Any relevant referral letters will also appear according to
your documented findings.
Click on the yellow ‘enable editing’ button
Complete the referral letter template by right clicking in each box and clicking
on add text, and record comments
TO E-MAIL REFERRAL for HIPS / MURMER / CARDIAC / Antenatally detected
Renal Anomaly-When referral letter is complete, copy e-mail address
click on ‘FILE’ in top left hand corner and select ‘save and send’ from the pick
list
Select ‘Send as attachments’ and then close the letter email in the normal way
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15.MEDWAY- search for the baby on Medway Maternity
16.Open up the baby record on Medway Maternity
17.Click into workflows
18.Choose ‘Assessments’, then choose ‘postnatal assessment’
19.Enter the date and time that the newborn examination was performed
20.Click ‘Next’
21.Type of assessment – choose ‘administration update only’ from the dropdown
menu
22.Location of assessment – choose the location where the NIPE exam was
performed from the dropdown menu
23.Complete the rest of the page.
24.Click ‘Next’
25.Choose ‘comments & discussion’ from the menu on the left-hand side of the
page
26.Enter the statement ‘NIPE recorded on SMART’ plus any other comments if
necessary i.e. hip referral etc.
27.Click ‘Back’, this saves the data and returns you to the work flow from the edit
screen
28.Close the workflow by clicking ‘complete workflow’ , complete and finish.
29. In Community setting System one, open a new journal entry, enter the
statement ‘NIPE recorded on SMART’ plus any other comments if necessary
i.e. hip referral etc.
References
 NICE (2006) Routine postnatal care of women and their babies NICE clinical guideline
no.37 NICE London
nd
 Tappero, E.P & Honeyfield, M E (1996). Physical Assessment of the Newborn 2
edition, Santa Rosa: NICU Ink
 Seymour J (1995). Who checks out? Health Professional Digest. Vol. 7 pp 8-9
 UK National Screening Committee ( 2012) Screening Tests for you and your baby
National Screening Committee London
 UK National Screening Committee (2012) Screening tests for your baby
26