Newborn And Infant Physical Examination Research Articles

The impact of the introduction of selective screening in the UK on the epidemiology, presentation, and treatment outcomes of developmental dysplasia of the hip.

Developmental dysplasia of the hip (DDH) can be managed effectively with non-surgical interventions when diagnosed early. However, the likelihood of surgical intervention increases with a late presentation. Therefore, an effective screening programme is essential to prevent late diagnosis and reduce surgical morbidity in the population. We conducted a systematic review and meta-analysis of the epidemiological literature from the last 25 years in the UK. Articles were selected from databases searches using MEDLINE, EMBASE, OVID, and Cochrane; 13 papers met the inclusion criteria. The incidence of DDH within the UK over the last 25 years is 7.3/1,000 live births with females making up 86% of the DDH population (odds ratio 6.14 (95% confidence interval 3.3 to 11.5); p < 0.001). The incidence of DDH significantly increased following the change in the Newborn and Infant Physical Examination (NIPE) guidance from 6.5/1,000 to 9.4/1,000 live births (p < 0.001). The rate of late presentation also increased following the changes to the NIPE guidance, rising from 0.7/1,000 to 1.2/1,000 live births (p < 0.001). However, despite this increase in late-presenting cases, there was no change in the rates of surgical intervention (0.8/1,000 live births; p = 0.940). The literature demonstrates that the implementation of a selective screening programme increased the incidence of DDH diagnosis in the UK while subsequently increasing the rates of late presentation and failing in its goal of reducing the rates of surgical intervention for DDH.

Examination of the Newborn: The Key Skills 4. The Testes

As the role of the midwife continually evolves and expands, midwives are increasingly performing the examination of the newborn. With a focus and national drive on providing continuity of care in conducting the newborn and infant physical examination (NIPE), many midwives view this assessment as a natural extension to their role1 and continually strive to provide high-quality, individualised care. In the penultimate edition of this five-part series, we consider the importance of the examination of the testes in the screening process. The significance of relevant history taking, knowledge of risk factors and a detailed examination of the testes will be explored, along with referral pathways in line with the requirements of the national screening programme. The impact of late detection and poor referral of undescended testes on the lives of children and adults will also be considered.

Examination of the Newborn: The Key Skills 3. The Hips

Midwives are increasingly performing the newborn and infant physical examination (NIPE), particularly now the new Nursing and Midwifery Council (NMC) education proficiencies are inclusive of the systematic examination of the newborn infant.1 This article, the third in the series, considers the importance of the examination of the hips in this screening process. The significance of history taking, knowledge of risk factors and the hip examination are explored. The necessity for early detection and treatment of hip abnormalities, along with referral pathways that Public Health England requires, are highlighted. The impact of late detection of developmental dysplasia of the hip on the lives of families and children are also considered.

Examination of the Newborn: The Key Skills 1. The Eye

Performing the newborn and infant physical examination (NIPE) is now recognised as part of the midwife’s sphere of practice. The majority of higher education institutions currently provide, or plan to include, NIPE training into their pre-registration curricula1 and many qualified midwives are embracing the NIPE role through undertaking continuous professional development modules.2 In the first of a five-part series, this article considers the importance of the eye examination in the screening process. The significance of history taking, knowledge of risk factors and the detection of the red reflex will be explored. The necessity for early detection of congenital cataracts, retinoblastoma and glaucoma, and the prerequisite referral pathways that the examination requires will also be highlighted.

Detection of anomalies in the red reflex test requires adequate training

ABSTRACT Clinical relevance Midwives should receive appropriate training to enable them to reliably detect an abnormality in the red reflex, so as to detect potentially sight‐ (and possibly life‐) threatening visual anomalies in newborns. Background Midwives who had completed the relevant Newborn and Infant Physical Examination (NIPE) training in the UK, were tested to determine whether they could reliably detect an abnormality in the red reflex of a model eye. Their results were compared to a group of undergraduate optometry students in their final year, who had considerably more experience with ophthalmoscopy. Methods Two groups of adult participants, 27 post‐graduate midwives and 10 undergraduate optometry students with different levels of experience in ophthalmoscopy were recruited. Participants were required to perform the red reflex test repeatedly on a set of 10 model eyes with interchangeable simulated retinas, that produced both normal and abnormal ‘red’ reflexes, under controlled conditions. Results A total of 1,810 observations were recorded across both groups of participants. Both the sensitivity and the specificity for distinguishing between normal and abnormal reflexes were higher for the optometry students (sensitivity 77.5 per cent and specificity 96.7 per cent) than the midwives (sensitivity 53.9 per cent and specificity 75.4 per cent). The positive predictive values were 21.7 per cent and 67.4 per cent for the midwives and optometry students, respectively. The negative predictive values were 92.8 per cent for the midwives and 98.0 per cent for the optometry students. Conclusion Despite completion of required training on the red reflex test, optometry students outperformed midwives in the detection of anomalous red reflex test simulations from a model eye. This result is likely due to differences in training in ophthalmoscopy between the two groups of participants. Additional training in the conduct of the red reflex test for midwives is therefore recommended.

Parents' expectations and experiences of the 6-week baby check: a qualitative study in primary care.

BackgroundThe Newborn and Infant Physical Examination (NIPE) programme requires all babies to have a comprehensive health check at 6–8 weeks of age. These are typically completed by GPs. Although person-centred care has achieved prominence in maternity care policy in recent years, there is limited empirical evidence on what parents and/or carers expect from the check, and how far experiences meet their needs.Aim To explore the expectations and experiences of parents attending their GP for a baby check.Design & settingA qualitative study was undertaken in primary care in London.MethodContent analysis was undertaken of transcripts of semi-structured interviews. Interviews were conducted with a total of 16 participants (14 mothers and two fathers) who had recently attended for a 6-week check for their baby.ResultsDespite the availability of plentiful sources of general advice on infants’ health and development, a thorough check by a trusted GP was an important milestone for most parents. They had few specific expectations of the check in terms of what examinations were undertaken, but even experienced parents anticipated reassurance about their baby’s normal development. Many also hoped for reassurance about their own parenting. Parents appreciated GPs who explained what they were doing during the examination; space to raise any concerns; and combined mother and baby checks. Referrals to secondary care were generally experienced as reassuring rather than a source of anxiety.ConclusionThe baby check meets needs beyond those of the NIPE screening programme. Protecting the time for a thorough consultation is important for parents at what can be a vulnerable time.

The 6 to 8-week check

The ‘6-week check’ is a head-to-toe assessment that forms part of the newborn and infant physical examination (NIPE). This NHS screening programme comprises two stages: the neonatal component takes place within 72 hours of birth, usually before discharge home, and the infant examination is performed between 6 and 8 weeks of age, typically in the community by the GP. The NIPE aims to detect abnormalities of the eyes, heart, hips and testes, and to ensure appropriate follow up of positive findings. It also presents an opportunity for care providers to monitor a child’s general health and development, and to provide information, health promotion, and support to parents and carers. This article seeks to describe in more detail the background and purpose of the infant check, to provide a systematic approach for performing the examination with a focus on four key conditions and to recommend referral pathways for positive findings.

Evaluation of primary care 6- to 8-week hip check for diagnosis of developmental dysplasia of the hip: a 15-year observational cohort study.

The current 6- to 8-week Newborn and Infant Physical Examination (NIPE) clinical assessment is a current standard hip-screening test in the community (England) to detect developmental dysplasia of the hip (DDH). To assess the value of the primary care 6- to 8-week clinical hip examination for the diagnosis of DDH. A single-centre 15-year observational cohort study at a district general hospital between 1 January 1996 and 31 December 2010. Those referred by the GP or community practitioner with suspected instability or abnormality of the hip joint (DDH), were clinically and sonographically examined in a specialist hip-screening clinic. Modified Graf Type III and IV, and radiological irreducible hip dislocation were considered to be 'pathological' hips. Screening failures were defined as those who had not been identified by this primary care screening assessment (but had irreducible hip dislocation). Secondary univariate and multivariable analyses were performed to determine which clinical findings are predictive of instability. Over the study period, there were 70 071 infants who underwent the 6- to 8-week clinical hip assessment. In the specialist hip-screening clinic, six (from the 170 referred) were diagnosed with pathological DDH. The sensitivity, specificity, positive predictive value, and negative predictive value for the 6- to 8-week clinical hip assessment were 16.7%, 99.8%, 3.5%, and 100.0%, respectively. A multivariable model showed a positive Ortolani manoeuvre to be the sole independent predictor of instability at 6 to 8 weeks. This 15-year study highlights the limitations of a hip check at 6 to 8 weeks. These findings support the reassessment of the national guidelines for this aspect of the NIPE DDH screening programme.

Exploring the experiences of student midwives completing the newborn infant physical examination

Background The newborn and infant physical examination (NIPE) is a screening programme now undertaken by specially trained midwives. It is increasingly a feature within pre-registration midwifery educational programmes. Objectives To explore the experiences of student midwives completing the theory and practice aspects of the NIPE within a pre-registration midwifery programme. Design A qualitative design was utilised to analyse data collected by semi-structured interviews. Method This study was conducted using interpretative phenomenological analysis (IPA). Findings Three superordinate themes were generated: learning by doing, mentorship and transition to qualification. The findings demonstrate the benefits of student midwife exposure to practical aspects of NIPE. Conclusions Findings indicate that standardisation is required with NIPE education and clinical practice. Preceptorship programmes must effectively prepare newly qualified midwives to undertake the NIPE role. Higher educational institutes must provide greater support to the midwives providing mentorship of student midwife NIPE practitioners. Further research should examine the maintenance of the NIPE role following qualification as a midwife.

Legal and ethical considerations for midwives performing the neonatal infant physical examination

The newborn and infant physical examination (NIPE) is part of a national screening programme in the UK that involves the first full physical assessment of the newborn. The examination aims to identify conditions and diseases early in order for prompt intervention and treatment to be arranged. Historically, the examination has lain solely in the paediatrician's remit; however, the more recent shift in midwifery care provision has led to a focus on midwifery-led care, continuity of carer and seamless care, which has brought the NIPE into the midwife's sphere of practice. There has been increasing evidence demonstrating that the midwife is the most suitable practitioner to conduct the NIPE following appropriate training; however, this has not been evaluated in recent years. Midwives are supported professionally, legally and ethically to conduct this examination, provided that they work within their sphere of practice and professional guidelines.

Streamlining the process of Newborn and Infant Physical Examination (NIPE)

This quality improvement project helped streamline the process of newborn and infant physical examinations on maternity inpatient ward and improved patient journey and workforce satisfaction.

Newborn and infant physical examination standards in a dedicated clinic for developmental dysplasia of the hip.

Introduction In 2014 our centre started a dedicated clinic for developmental dysplasia of the hip (DDH). The aim of the clinic was to streamline DDH referrals, enabling timely review, imaging and multidisciplinary treatment. Ongoing audit has been carried out based on the UK National Screening Committee newborn and infant physical examination (NIPE) guidelines, first published in 2008. Methods A three-year prospective audit was undertaken between 2014 and 2016 assessing compliance with NIPE standards (ST2b and ST2d) relating to timeliness of expert consultation following positive ultrasonography findings of DDH with positive examination or risk factors. Results A total of 257 babies born between January 2014 and December 2016 were seen in our dedicated DDH clinic, with 106 with abnormalities on ultrasonography and 54 requiring treatment. Compliance with 'expert consultation within 4 weeks of age for babies with an abnormality detected on clinical examination and positive ultrasonography' improved from 50% in 2014 to 53% in 2015 and 71% in 2016. Compliance with 'expert consultation within 8 weeks of age for babies with positive risk factors, negative examination and positive ultrasonography' improved from 65% in 2014 to 93% in 2015 and 100% in 2016. Conclusions This prospective audit assessing timeliness of expert consultation has demonstrated ongoing improvements between 2014 and 2016. A greater proportion of babies with ultrasonography evidence of DDH have been seen at the appropriate time. In the majority of cases, this has enabled timely non-invasive treatment with a Pavlik harness rather than surgery.

Newborn and Infant Physical Examination: Motivating Midwives after ‘Training’

Increasingly, the call to incorporate the screening activities of Newborn and Infant Physical Examination (NIPE) as part of the professional remit and the public health role of the midwife has been heeded, illustrated by an increase in the inclusion of the training in both pre-registration and post-registration courses. However, the underutilisation of the skills attained upon completion of training remains evident. Issues that impact on perceptions of empowerment and autonomy in the role may be contributors to the problem. Clear professional boundaries with a focus on low-risk newborns; an increase in the value placed on the extended role, by both midwives and paediatricians; investment in resources that support continuous professional development – could all be an answer to the problem.

Self-assessment

A male baby was born in a midwifery-lead unit by normal vaginal delivery at 38 + 5 weeks gestation weighing 2.8 kg. There were no risk factors for sepsis and the nulliparous 24-year-old mother received normal antenatal care. There was thin meconium shortly before delivery but no other antenatal complications. There was no initial respiratory distress and the baby breast fed well at 1 hour of age. On maternal request, mum and baby were discharged home at 4 hours of age with a community midwife NIPE (newborn and infant physical examination) booked for the same day.

National survey of current practice standards for the newborn and infant physical examination

Objectives: To determine compliance with recommended standards for the newborn and infant physical examination (NIPE), identify which professionals were performing the NIPE and determine standards for screening and management of babies at risk of developmental dysplasia of the hip (DDH) or congenital heart disease (CHD). Design: In autumn 2014, an online questionnaire was sent to all heads of midwifery in the UK. Key findings: Completed questionnaires were returned from 64.3% (n=99/154) of targeted NHS Trusts. The main professionals performing the NIPE were paediatricians, midwives and neonatal practitioners. 95% of responding Trusts employed midwives qualified to perform the NIPE, with 13.7% of midwives employed in the UK NIPE-qualified. Midwives performed over 50% of NIPEs in more than 20% of Trusts where babies were born in the consultant-led delivery suite, and 70% of Trusts where babies were born in a midwifery-led setting. All respondents believed the optimum time for the NIPE was before 72 hours, and all but one Trust usually achieved this. Overall, nearly 80% of respondents rated the value of NIPE as a screening tool as ‘good’ or ‘excellent’. Conclusions: Despite evidence for the safety and cost-effectiveness of midwives examining the newborn, plus previous recommendations for expanding NIPE training, the number of NIPE-qualified midwives remains low. Considerable variation was found between Trusts for screening for DDH and CHD. Implications for practice: The few midwives with NIPE training are examining far more babies than those in their caseload, which undermines the principles of continuity of care. There is scope for improvement in the quality and consistency of information to parents and follow-up processes. There is a need for the development of more robust guidelines for practice and improved screening for neonates.

Prevalence of Depression Symptoms in Outpatients with a Complaint of Headache

This case-control study was designed to determine whether adults who present to a primary care office with a chief complaint of headache have more reported symptoms of depression than adults presenting with other problems. Adult, English-speaking patients who presented to a primary care office with a chief complaint of headache were matched to adult patients of the same age and sex who presented with problems other than headache. All participants completed the PRIME-MD 9-item Patient Health Questionnaire as a screen for depression. A total of 200 participants entered the study. The mean age of the participants was 43.8 years (range, 18-87 years). Women constituted 84% of the participants. Of those patients who presented with headache, 32% had a likelihood of possible major depressive disorder compared with 12% in the patients presenting without headache. Almost one-third of adult patients who present to a primary care office with a complaint of headache report moderate symptoms of depression when screened compared with approximately 10% of patients presenting with a complaint other than headache. Given such a high prevalence of these symptoms, primary care physicians should screen all adult patients who present with headache for depression.