Newborn Examination (NIPE)
Author – Dr Elizabeth Hatton Editor – Dr Kalyani Shinkar
Last updated 16/02/25
Table of Contents
Introduction
The Newborn and Infant Physical Examination (NIPE) is a screening examination that aims to identify congenital anomalies relating to the heart, hips, eyes and testes. It is part of the national screening programme that is conducted on all babies in the UK. It should be completed within 72 hours of birth, and again at 6-8 weeks of age in a GP setting. When performing a NIPE in an OSCE setting, it is essential to follow a systematic approach by conducting the examination sequentially from head to toe.
Equipment
The following equipment is required:
- Stethoscope
- Ophthalmoscope
- Measuring tape
- Tongue depressor
Starting the Examination
- Introduce yourself to the parents. The exam should ideally take place with parents present to give them the opportunity to ask questions throughout
- Explain what the examination involves and gain full consent before proceeding
- Ask about any complications that occurred during pregnancy and delivery
- Ask about any significant family history, including childhood heart, hip or eye problems affecting first degree relatives
- Ask the parents if the baby has passed urine and meconium
- Although having a structure of head-to-toe is useful to make sure nothing is missed, the NIPE is an opportunistic examination
1. General Inspection
Completely undress the baby. Observe for:
- Colour
- Cyanosis
- Jaundice
- Pallor
- Respiratory distress
- Posture
- Abnormal movements
2. Weight
Record the baby’s weight and check if the baby is:
- Small for gestational age (<10th centile)
- Appropriate weight for gestational age (10th-90th centile)
- Large for gestational age (>90th centile)
If weight is disproportionately low (i.e. appropriate head circumference but low weight), this suggests asymmetrical growth restriction – typically due to placental insufficiency
If low weight is proportional to the baby’s head circumference (i.e. small head and low weight), this may be due to foetal factors such as intrauterine infection or genetic abnormality.
3. Tone
Assess tone when picking up the baby to undress them and gently move the baby’s limbs individually. Hypotonic babies have been described to be like ‘rag dolls’ on handling. They may struggle with feeding and cannot maintain a proper suck-swallow pattern when breastfeeding.
4. Head
- Assess head size and shape
- Head Size: Head circumference should be measured from occiput to frontal bone and be plotted on a newborn growth chart
- Microcephaly: head circumference is smaller than expected for gender and age
- Macrocephaly: head circumference is larger than expected for gender and age
- Head Shape: Head swellings are common after birth, especially following instrumental delivery. An overview of key head swellings is shown below
- Head Size: Head circumference should be measured from occiput to frontal bone and be plotted on a newborn growth chart
- Palpate the suture lines
- Suture abnormalities may impact head shape. Examples of suture abnormalities include:
- Overriding sutures
- Craniosynostosis (premature fusion of skull sutures)
- May require surgery and genetic referral
- Suture abnormalities may impact head shape. Examples of suture abnormalities include:
- Palpate the anterior fontanelle
- A sunken fontanelle may indicate dehydration
- A bulging fontanelle may indicate raised intracranial pressure
| Caput Succedaeneum | Cephalohaematoma | Subgaleal Haemorrhage | |
|---|---|---|---|
Definition | Subcutaneous fluid collection above the periosteum | Blood collection between skull periosteum and bone | Blood accumulation in subgaleal space |
Presentation | Crosses suture lines | Bounded by suture lines | Fluctuant swelling that crosses suture lines |
Prognosis | Self-resolving after 12-18 hours | Most resolve spontaneously by 3-4 months | Can cause life-threatening blood loss |
Action | None | Monitor for jaundice | Check haemoglobin Monitor for jaundice Measure head circumference daily |
5. Face
Assess for:
- Dysmorphic features suggestive of underlying genetic conditions
- Facial asymmetry indicating facial nerve palsy
- Facial trauma e.g. lacerations, bruising, scratches
- Choanal atresia (obstructed nostril)
- Bilateral choanal atresia can cause respiratory distress in the neonate
- Block each nostril and assess for evidence of respiratory distress
Ears
- Inspect the pinna for any skin tags, asymmetry or accessory auricles
- Check for atypical positioning of the ears
- Draw a horizontal straight line from the outer corner of the eyes. The superior portion of ears should meet this line. If it does not, the patient may have low-set ears
- All babies require a hearing test predischarge
Eyes
Assess:
- Eye position and symmetry
- Are the eyes widely spaced?
- Are the palpebral fissures pointing upwards or downwards?
- Erythema or discharge suggesting conjunctivitis
- Sclera discolouration (e.g. jaundice, subconjunctival haemorrhage)
- Fundal reflex
- Hold the ophthalmoscope about an arm’s length away from the baby
- Hold the ophthalmoscope to your eye and direct the light toward the baby’s eyes
- Observe for a reflection in the pupil
- In babies with lighter skin, the fundal reflex is normally red/orange. In babies with darker skin, the fundal reflex may be yellow/white or even blue
- An absent red reflex requires immediate ophthalmology referral. Causes of an absent red reflex include:
- Congenital cataract
- Vitreous haemorrhage
- Retinal detachment
- Retinoblastoma
- Eye position and symmetry
Image 1: Normal red reflex in white, Asian, and black babies
Mouth and Palate
- Visually inspect the baby’s mouth to assess for cleft palate. Use a torch and tongue depressor to visualise the whole of the palate, including the uvula
- Cleft lip or palate are commonly an isolated congenital anomaly, but may be associated with other medical conditions
- Cleft in the hard palate or cleft lip may be easy to detect on visual examination
- However, clefts in the soft palate may be more difficult to visually detect
- Refer cleft lip or palate to an ENT specialist and the infant may require help with feeding
- Inspect the tongue to assess for ankyloglossia (tongue-tie). The TABBY tongue assessment tool can be used to formally evaluate the presence and severity of tongue-tie in infants, especially in the context of breastfeeding difficulties
- Examine the jaw and mouth by inserting a gloved index finger into the mouth – the infant should reflexively suck on your finger
- Feel the hard palate in the anterior mouth and soft palate as your fingers travel backwards
6. Neck
- Inspect the neck for abnormalities such as webbing (associated with Turner syndrome) and neck torticollis (when neck is twisted to one side caused by injury to the sternocleidomastoid muscle during birth)
- Inspect and palpate for neck lumps e.g. cystic hygroma
- Assess for evidence of clavicular fracture by running your fingers along the clavicles (clavicles should feel smooth) and inspecting for asymmetry of the shoulders, asymmetry of movement in the affected arm, and pain and distress on movement of the arm)
- Clavicular fractures are associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight.
7. Chest
- Assess work of breathing. Signs of increased work of breathing include:
- Tachypnoea (normal respiratory rate is 40-60)
- Subcostal recessions
- Intercostal recessions
- Nasal flaring
- Grunting
- Tracheal tug
- Note – It is normal for infants to take short pauses in their breathing or breathe at a slightly irregular rate (called periodic breathing)
- Inspect for pectus excavatum (the chest appears ‘caved in’) or pectus carinatum (protrusion of the sternum)
- Assess the baby’s chest expansion – is it symmetrical?
- Auscultate lung sounds both anteriorly and posteriorly
- Assess the baby’s heart rate. Normal heart rate in a newborn is 120-160 beats per minute
- Auscultate the heart sounds using the bell and then the diaphragm. Note any added heart sounds
- Make sure to auscultate in the left infraclavicular region (to assess for patent ductus arteriosus) as well as the left infrascapular region (to assess for aortic coarctation)
- To screen for congenital heart disease, assess pre-ductal (right arm) and post-ductal (either leg) oxygen saturations. The readings should be ≥95% and the difference in oxygen saturation between the right arm and leg should be <3%.
8. Abdomen
- Inspect for abdominal distension – causes include feeds, swallowed air or bowel obstruction
- Check the condition of the umbilical cord. Erythema and discharge may suggest infection of the umbilical cord (omphalitis)
- Palpate for organomegaly
- Liver – normally felt 1cm below the subcostal margin
- Spleen
- Kidney – if palpable, consider polycystic kidney disease
- Bladder – if palpable, consider urinary tract obstruction
9. Genitalia
- Palpate femoral pulses
- Bounding femoral pulses are present in diseases associated with increased pulse pressure e.g. patent ductus arteriosus
- Weak, absent or delayed femoral pulses on one side may indicate aortic coarctation
- Check for inguinal hernia
- Evaluate the genitalia. If there is any ambiguity, senior review is urgently required
- Male Genitalia:
- Inspect the position of the urethra.
- Hypospadiasis: urethral opening is on the ventral surface (underside) of the penis
- Epispadiasis: urethral opening is on the dorsal surface of the penis
- Assess the size of the penis. It should be at least 2cm
- Palpate the scrotum for testes
- Unilateral undescended testes are common, and should be followed up by a clinician (most likely the baby’s GP) in 6 weeks
- Bilateral impalpable testes require urgent senior review
- Inspect the position of the urethra.
- Female Genitalia:
- Inspect the labia and ensure they are not fused. In preterm/SGA babies, the labia minora may be more prominent
- Inspect the clitoris and ensure it is appropriately sized
- Due to exposure to maternal oestrogens, babies may have white vaginal discharge. This is a normal finding
- Male Genitalia:
- Examine the hips by performing Barlow and Ortolani’s tests
- These tests screen for developmental dysplasia of the hip (DDH), which is when the hip joint does not form properly (i.e. the head of the femur does not sit fully within the acetabulum).
- Risk Factors for DDH include:
- Family history – childhood hip problems in a first degree relative
- Female gender
- Breech presentation
- Multiple pregnancy
- First-born babies
- Barlow’s manoeuvre is used to identify an unstable hip. The baby is placed supine, and the hip is flexed to 90 degrees. The hip is adducted whilst applying posterior pressure to the knee. This causes the femur to posteriorly dislocate from the acetabulum. A palpable clunk may be heard, which represents a positive test.
- Ortolani’s manoeuvre is used to confirm a posteriorly dislocated hip. The baby is again supine with hips flexed to 90 degrees. From an adducted position, the hip is gently abducted and the femoral trochanter is pushed anteriorly. A palpable clunk indicates the femur has gone back into the acetabulum.
- A positive screen occurs if there is suspected dislocated or dislocatable hip(s) on examination
- Babies with a positive test result require a hip ultrasound scan
10. Extremities
- Upper Limbs
- Assess for tone, movement and compare length of the upper limbs, noting any discrepancy
- Assess for Erb’s palsy and Klumpke’s palsy (brachial plexus injury)
- Associated with shoulder dystocia, traumatic or instrumental delivery and large birth weight
- Palpate the brachial pulses on each arm
- Count the fingers on each hand, noting any abnormality e.g. syndactyly
- Inspect the palms and observe the palmar creases – normally two creases are present
- A single palmar crease could indicate Down’s syndrome or may be an insignificant finding (it is present in around 1% of the general population)
- Lower Limbs
- Assess for tone, movement and compare length of the lower limbs, noting any discrepancy
- Count the toes on each foot, noting any abnormality e.g. syndactyly
- Note the position of the feet and observe if talipes, also known as clubfoot, is present
- Talipes is when the foot is turned inwards and may be positional or fixed
- Positional talipes: the position of the foot can be corrected by moving it and may require physiotherapy referral
- Fixed talipes (congenital talipes equino varus): the position of the foot cannot be corrected by moving it and requires orthopaedic referral and DDH work-up
- Talipes is when the foot is turned inwards and may be positional or fixed
11. Back and Anus
- Inspect and palpate the spine, assessing for:
- Any spinal cord abnormality (neural tube defects)
- Hair tufts
- Sacral pits
- Scoliosis
- Skin integrity
- Inspect for any rashes or birthmarks
- Assess patency of the anus by gently spreading apart the gluteal cleft
Some common benign skin changes include:
| Erythema Toxicum | Milia | Congenital Dermal Melanocytosis (Mongolian Blue Spot) | Port Wine Stain | |
|---|---|---|---|---|
Explanation | Erythematous macules, papules and pustules that typically wax and wane over several days | Small white cysts, often seen on the nose, but may be more widely distributed across the scalp, face and trunk | Blue-grey patches, most commonly affecting the sacral and lumbar regions More common in children of Asian, African, Middle Eastern or Mediterranean descent | Smooth, flat, pink/purple patch If presenting in an ophthalmic (V1) distribution, consider Sturge-Weber syndrome. Discuss with a senior paediatrician about neuroimaging to assess for intracranial capillary-venous malformations |
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Abnormal skin findings include:
- Vesicular rash in Herpes infection
- Café au lait spots in neurofibromatosis
- Jaundice
12. Neurological Examination
- Assess the baby’s mental status, which can be described as:
- Awake or asleep
- Irritable or calm
- Consolable or inconsolable
- Tone
- Motor function, which can be assessed by observation:
- Does the infant move all their extremities well?
- Is their face symmetrical?
- Reflexes – all healthy babies should have the following primitive reflexes up to 6 months of age:
- Palmar grasp reflex: place your finger in the baby’s palm and the baby’s fingers should close around it
- Rooting reflex: stroking the baby’s cheek should cause them to start sucking their mouth in anticipation of a feed
- Sucking reflex: place a gloved finger in the roof of the baby’s mouth and the baby should suck. This reflex fully develops by ~36 weeks gestation
- Moro reflex: gently lift the baby’s head and shoulders slightly off the surface, allowing the head to drop back slightly while still supporting it. The baby should suddenly spread their arms and legs (abduction) then extend their fingers. This is followed by quick flexion (arms are brought together) as if trying to grasp something.
- Plantar reflex: also known as the Babinski reflex, this reflex is tested by stroking the sole of the foot from the heel towards the toes. The normal response in infants under the age of 1 is dorsiflexion (i.e. the toes bend upwards)
- Stepping reflex: holding the baby upright with their feet touching a flat surface should result in the baby making stepping movements as if trying to walk
- Sensation – assess how the baby responds to your touch
Finishing the Examination
- Explain to the baby’s parents that the examination is complete, and explain the findings, including any referrals or senior reviews that may be required
- Document your findings and complete any necessary referrals
- A copy of the NIPE should be available for the baby’s notes, the baby’s red book and the health visitor
- Newborn and infant physical examination (NIPE) screening programme handbook(no date) UK. Available at: https://www.gov.uk/government/publications/newborn-and-infant-physical-examination-programme-handbook/newborn-and-infant-physical-examination-screening-programme-handbook#newborn-and-infant-physical-screening-examination-nipe
- https://www.nhs.uk/conditions/baby/newborn-screening/physical-examination/