Newborn Infant Physical Examination Guideline - PDF document

1 Newborn Infant Physical Examination Guid
Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database \ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 1 of 10 Document Control Title Newborn Infant Physical Examination Guideline Author Author’s job title Antenatal & Newborn Screening Coordinator Co n sultant Paediatrician Directorate Maternity Services Department Women’s & Children’s Version Date Issued Status Comment / Changes / Approval 0.1 J an 2016 Draft Initial version for consultation 1.0 Feb 2016 Final Approved by Maternity Services Guideline Group 1.1 Apr 2017 Revision Approved by Maternity Services Guideline Group . Additions to 3. Screening Process 2.0 October 2017 Final Minor amendments by the Antenatal & Newborn Screening Coordinator. Approved by the Maternity Services Guideline Group. Main Contact Antenatal & Newborn Screening Coordinator Ladywell Unit North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB Tel: Direct Dial – 01271 314037 Tel: Internal - 4037 Lead Director Director of planned care and surgery Superseded Documents Newborn Infant Physical Examination Guideline v1.1 Issue Date October 2017 Review Date October 2020 Review Cycle Three years Consulted with the following stakeholders: (list all)  Paediatricians  Midwives Approval and Review Process  Maternity Services Guideline Group Local Archive Reference G: \ CorporateGovernance \ Published Policy \ Maternity Local Path Maternity Services \ folder Filename Newborn Infant Physical Examination Guideline v1. 2 Policy categories for Trust’s internal website (Bob) Maternity Services Tags for Trust’s internal website (Bob) Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database

2 \ Maternity \ newborn & Infant physical
\ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 2 of 10 CONTENTS Document Control ................................ ................................ ................................ ........................ 1 1. Purpose ................................ ................................ ................................ ................................ 2 2. Background ................................ ................................ ................................ .......................... 2 3. Screening Process ................................ ................................ ................................ ................. 3 4. Referral when abnormality detected. ................................ ................................ .................... 5 5. Babies who have missed Newborn Infant Examination Screening ................................ .......... 6 6. Education & Training ................................ ................................ ................................ ............ 6 7. Monitoring Compliance with and the Effectiveness of the Guideline ................................ ...... 7 Standards/ Key Performance Indicators ................................ ................................ ......................... 7 Process for Implementation and Monitoring Compliance and Effectiveness ................................ 7 8. References ................................ ................................ ................................ ........................... 7 9. Associated Documentation ................................ ................................ ................................ ... 8 Appendix: 1 ................................ ................................ ................................ ................................ . 8 1. Purpose 1.1. The purpose of this document is to detail the process for the implementation of the Newborn Infant Physical Examination . 1.2. The policy applies to Midwives & Paediatricians. 1.3. Implementation of this

3 policy will ensure that:  All eli
policy will ensure that:  All eligible babies where screening has been discussed, offered and acc epted: are screened with 72 hours of birth.  All babies who require a further specialist referral are seen within the timeframe set out in the National Screening Committees Newborn Infant Physical Examination Standards & Competencies (2008) https://www.gov.uk/government/uploads/system/uploads/attachme nt_data/file/401611/NSC_Standards___Competencies_2_.pdf 2. Background The aim o f the Newborn Infant Physical Examination (NIPE) is to detect less obvious adverse conditions or abnormalities. It includes screening for congenital cardiac defects , developmental dysplasia of the hip, some ocular disorders including congenital cataract) a nd undescended testes as well as a general physical examination . Almost immediately after a baby is born, an initial physical examination is performed by the Midwife or Paediatrician attending the birth, to exclude any visible physical abnormalities and/or dysmorphic features. Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database \ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 3 of 10 A comprehensive Newborn Infant examination should be performed within 72 hours, by a paediatrician or a Midwife who has completed and successfully met the assessment criteria of the Examination of the Newborn Course. This examination should be repeated by the General Practitioner between 6 - 8 weeks of age. Although screening is performed universally on all babies this guideline, applies to well babies only. This is because some babies maybe ill and/or premature at the time the examinat ion is due and some components have to be deferred. 3. Screening P rocess  All parents to be offered NIPE screen for their baby within 72 hours of birth either by a paediatrician or midwife on the postnatal ward or at home in the case of homebirth or early discharge from deliver

4 y suite.  Baby’s details to be
y suite.  Baby’s details to be documented clearly in paediatric work book by midwife, on transfer to Bassett ward. Paediatrician/midwife to obtain consent from parents before examination.  Baby barcode identification label to be used when documenting examination in neonatal notes and personal child health record (PCHR). Details on baby barcode identification labels should be checked by the parent for accuracy before use.  If baby’s barcode identification label is un - available, baby details including NHS number to be obtained from the electronic patient records and checked with parent for accuracy.  Consent and findings of examination to be documented on the NIPE Smart IT sys tem , two printed copies of the NIPE screen should be placed in the Child’s Personal Health Record (red book), one copy for the parent’s and one for the Health Visitor.  A Printed c opy of the NIPE screen to be forwarded to the child health record department .  Findings of the examination should be reported immediately to the parents and documented clearly in the neonatal postnatal notes .  It is the responsibility of the discharging hospital midwife to confirm the NIPE screen has been offered and where accepted completed or examination arranged. This should be clearly documented in the neonatal postnatal notes and on Trackcare .  The community midwife should confirm the NIPE screen has been completed at each home visit.  If parents decline the NIPE screen the Antena tal & Newborn Screening coordinator should be informed for further discussion with parents. Babies in Special Care Baby Unit (SCBU) Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database \ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 4 of 10  Babies in the special care baby unit should be assed and if well enough the NIPE

5 screen should be undertaken by 72 hour
screen should be undertaken by 72 hours of age.  Some babi es may be too ill at the time the examination is due and the NIPE screen is not appropriate. Please document baby is in NICU on the NIPE SMART IT system  If possible all screening elements should be undertaken but if not, the NIPE screen should be completed as soon as possible.  Some elements of the NIPE screen may need to be repeated in very preterm babies, but referrals should still be made as per national standards as regard screen positive cases.  Referral timescales should not be adjusted for preterm babies. Components of the General Physical Examination  A review of the medical history including: family history, maternal, antenatal and perinatal history, infant fetal and neonatal history including any previously plotted birth - weight and head circumference.  A review of parental concerns.  Feeding Initial Communication  Whether the baby has passed meconium and urine(and if seen the nature of the urine stream in a boy)  Observe the baby’s appea rance including colour, breathing, behaviour, activity and posture.  Examine fontanelles, face, and nose , mouth including palate, ears, neck and general symmetry of head, vault, sutures, fontanelles and facial features. Check eyes - opacities and ‘Red reflex ’  Examine the neck and clavicles, limbs, hands, feet and digits, assessing proportion and symmetry. Cardiovascular system - heart rate, rhythm and sounds, m urmurs and femoral pulse volume  Respiratory system - effort rate and lung sounds.  Abdomen - shape and p alpate to identify any organmegaly. Check condition of the umbilical cord. Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database \ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 5 of 10  Genitalia and anus. Check anus for patency. Check genitalia for form and undescended testicles

6 in males.  Spine - inspect and
in males.  Spine - inspect and palpate bony structures and integrity of skin.  Skin - note, the colour and texture of the skin as well as any birthmarks or rashes.  Central nervous system - observe tone, behaviour, movements and posture and elicit newborn reflexes only if concerned.  Hips - check symmetry of the limbs and skin folds. Perform Ba rlow and Ortolani’s manoeuvres .  Cry - If heard, note sound of baby’s cry. Further communication Record details, including time and age of baby at examination, location of examination, problems identified, referrals made and discussions with parents in the neonatal postnatal notes and Personal child health record. Guidance for early discharge In the c ase of early discharge from hospital the National Screening Committee Programme (2014) recommends that:  Babies be offered the Newborn Infants Physical Examination before dischar g e, even if this is at or before 6 hours of age  The examination maybe delayed beyond 6 hours if arrangements are made for it to be completed:  Within 72 hours on Bassett ward. Baby’s details to be documented in the paediatric work book and community midwife to be informed by hospital midwife if they do not attend.  In the community by an appropriately trained midwife.  The arrangements should be clearly documented in the neonatal postnatal notes and on STORK. 4. Referral when abnormality detected.  Where an abnormality is found or expected and further follow up is necessary referral is to be made, by the clinician undertaking the examination (Appendix 1 ) . Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database \ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 6 of 10  All findings and referrals to be discussed immediately with parents and doc umented on the NIPE SMART IT system  Babies with an abnormality of th

7 e eye should be referred and attend an a
e eye should be referred and attend an assessment appointment with a Consultant Ophthalmologist by 2 weeks of age.  Babies who are found to have dislocated or dislocatable hips, positive Ortolani or Barlow manoeuvre on NIPE s hould be referred using the printed NIPE Smart referral form, for hip ultrasound within 2 weeks of age.  Babies who have risk factors but normal NIPE should be refer red using the printed NIPE Smart referral form and undergo hip ultrasound within 6 weeks of age.  First degree relative.  Breech presentation at or after 36 completed weeks of pregnancy , irrespective of presentation at delivery or mode of delivery.  Breech presentation at delivery if this is earlier than 36 weeks.  In the case of multiple birth: if any of the babies is breech presentati on, all babies in the pregnancy .  Babies who are found to have bilateral undescended testes to be reviewed by a senior paediatrician within 24 hours to rule out metabolic and intersex conditions.  Where a baby is found to have a heart abnormality , the examining practitioner should discuss findings with a senior paediatrician and refer as appropriate. Urgency will depend on the assessment of the clinical condition of the baby.  When further action is required this should b e discussed with the registrar on call for SCBU. If unavailable then discuss with the consultant on call.  The consultant must be informed when a referral is required to another speciality. 5. Babies who have missed Newborn Infant Examination Screening Infants up to and including three months of age.  If newborn examination has not been performed, it should be undertaken as soon as possible.  If a late Newborn Infant Physical Examination was performed at or after 6 weeks of age, it is not nec essary to undertake it again. 6. Education & Training The NIPE is carried out by doctors or by midwives. Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database

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\ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 7 of 10 Midwives are required to achieve post - basic learning, work in a framework of professional supervision, and maintain competence to carry out the physical examination and screening of the newborn. Doctors are expected to demonstrate on - going professional dev elopment Each practitioner is accountable for their practice and is required to maintain their competencies and knowledge, for midwives in accordance with the Maternity Services Training needs analysis (201 7 ) 7. Monitoring Compliance with and the Effectivenes s of the Guideline Standards/ Key Performance Indicators 7.1. Key performance indicators comprise:  NP1 Total number of eligible babies screened within 72hrs  NP2 The number of babies on physical examination, indicates that an ultrasound assessment for developmen tal dysplasia of the hips is required, are seen for specialist hip ultrasound within 2 weeks of birth. Process for Implementation and Monitoring Compliance and Effectiveness 7.2. Guideline to be included in ‘Risky Busi ness’, bi - monthly newsletter . 7.3. Compliance wi ll be monitored via  Quar terly Key performance NP1 & NP2 data.  Annual audit of 5 sets of notes by Antenatal & Newborn Screening Coordinator.  Risk Management process 8. References  UK National Screening Committee (UKNSC) (2008) Newborn and Infant Examination: Standards and Competencies.  National Institute for Health and Clinical Excellence (2006) Routine postnatal Care of women and their babies Clinical Guideline 37 London: NICE  UK National screening Committee (UKNSC) (2014) Programm e Statement: Early Postnatal Disc h arge. Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database \ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 8 of

9 10  UK National screening Commit
10  UK National screening Committee (UKNSC) (2014) Programme Statement Guidance - Babies who have missed NIPE screening. 9. Associated Documentation  Antenatal & Newborn Screening Guideline (2015) .  Maternity Services Training Needs and Training Delivery Strategy (2013). Appendix : 1 Abnormal examination findings Referral Ambiguous genitalia Urgent Registrar review Anal abnormality Check opening bowels Registrar review Antenatal renal pelvis dilatation Registrar review USS kidneys BCG (tuberculosis risk) BCG to be performed in Children’s out patients department https://www.gov.uk/government/uploads/system/upl oads/attachment_data/file/491527/WHO_estimates_ of _tuberculosis_incidence_by_country__2014_v2.pdf Brachial plexus injuries X - Ray shoulder Refer to community children’s physiotherapist Out patients follow up with consultant in 4 weeks Choanal atresia Registrar review Clavicle fracture Registrar review. Referral for x - ray Prescribe analgesia Cleft lip/palate Registrar review Eyes Registrar review. Referral and consultant ophthalmology appointment Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database \ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 9 of 10 within 2 weeks Facial palsy Reassure parents Prescribe Hypromellose eye drops Children’s outpatient appointment in 6 weeks - parents to cancel if resolved Femoral pulses absent Urgent registrar review Gynaecomastia Reassure Heart Registrar review and discussion with senior paediatrician. Refer as appropriate, urgency will depend on the assessment of t he clinical condition of the baby. Maternal Hepatitis B positive http://ndht.ndevon.swest.nhs.uk/policies/wp - content/uploads/2015/08/Hepatitus - B - in - Pregnancy - Guidelines - V2.0 - 14Aug15.pdf Hepatitis B risk factors http://ndht.ndevon.swest.nhs.uk/policies/wp - content/uploads/2015/08/

10 Hepatitus - B - in - Pregnancy - Guideli
Hepatitus - B - in - Pregnancy - Guidelines - V2.0 - 14Aug15.pdf Hepatitis C risk factors http://ndht.ndevon.swest.nhs.uk/policies/wp - content/uploads/2010/05/Hepatitis - C - in - Pregnancy - Guideline - V1.0 - 18Dec13.pdf Hernia (inguinal) Registrar review Surgical review locally then contact surgic al registrar in Bristol Children’s Hospital Hernia (umbilical) Reassure Hip instability Urgent Registrar review. Referral for ultrasound of hips within 2 weeks of age. Hydrocele Write to GP and ask to refer to surgeons if does not resolve Hypospadia / Epispadia Registrar review Referral letter Bristol Children’s Hospital, Urology Advise parents not to have baby circumcised. Jaundice https://www.nice.org.uk/guidance/cg98 Newborn Infant Physical Examination Guideline FINAL FEB16 Maternity G: \ Corporate Governance \ Compliance Team \ Policies Procedural Documents \ Published Policy Database \ Maternity \ newborn & Infant physical examination guidelines \ Newborn Infant Physical Examination Guideline v2.0.docx v2.0 Page 10 of 10 Petechial rash – generalised Registrar review, Full Blood Count Polydactyly (extra digits) Registrar review Pre - auricular skin tags If no other problems, GP to refer to plastics for cosmetic reasons at 1 year. Red reflex absent Registrar review within 24 hours Referral and appointment with Consultant Ophthalmologist by 2 weeks of age. Sacral pit/dimple If Isolated sacral dimples & small pits which are 5 mm from the midline & 5 mm from the anus reassure. Registrar review. Syndactyly (webbed digits) Registrar review Talipes (fixed) Registrar review. Physiotherapy referral. Referral for hip ultrasound at 6 weeks Talipes (positional) Consider physiotherapy Teeth Dental opinion and removal if loose Tongue Tie http://ndht.ndevon.swest.nhs.uk/policies/wp - content/uploads/2014/11/Tongue - Tie - in - Infants - Guideline - V2 - 0 - 12Nov14 - a.pdf Tes tes bilateral undescended Urgent registrar referral (Appendix 2) Testes unilateral undescended To be reviewed by GP at 6weeks Vaginal tags Resolve without treatme