The newborn and infant physical examination (NIPE) is an integral part of child health surveillance in the UK, with current standards recommending all babies have a NIPE performed within 72 hours of birth and again at 6-8 weeks of age (Hall and Elliman, 2003; National Institute for Health and Care Excellence (NICE), 2006; UK National Screening Committee (UKNSC), 2008).
Background
Traditionally, the NIPE was performed by paediatric senior house officers (SHOs); however, changes to the organisation and provision of maternity services provided the impetus for other professionals, particularly midwives developing their practice, to include responsibility for NIPE within their professional scope. The cost-effectiveness of developing the midwife's role to include the NIPE was demonstrated in a study by Townsend et al (2004). This study comprised several arms, including a randomised trial of 826 mother-and-baby pairs (Wolke et al, 2002; Bloomfield et al, 2003a; 2003b; Hayes et al, 2003; Rogers et al, 2003; Townsend et al, 2004), to either a midwife examination or an examination by a SHO; a comparative study of the appropriate referral rates; and a video assessment comparing the quality of midwives' and SHOs' examinations (Bloomfield et al, 2003b). The study reported significantly greater maternal satisfaction with neonatal examinations performed by midwives than by SHOs (OR 0.54, 95% CI 0.39-0.75, P<0.001), and concluded that developing the role of the midwife to include the NIPE would not only increase maternal satisfaction with the NIPE, but would also result in improved quality of the examination and a reduction in health service costs (Townsend et al, 2004). Practice recommendations arising from the study included extending the midwife's role to include the NIPE and expanding the criteria for babies suitable for midwives' examination. Consideration to include the NIPE as part of the pre-registration education of midwives was also recommended (Wolke et al, 2002; Bloomfield et al, 2003a; 2003b; Hayes et al, 2003; Rogers et al, 2003; Townsend et al, 2004).
Since the publication of the EMREN study (Townsend et al, 2004) national standards for the NIPE have been published by the United Kingdom National Screening Committee (UKNSC, 2008). These standards address a number of different aspects of the examination including the timing, information given to parents, training and competencies of professionals, as well as specific standards for the screening of the eyes, hips, heart and testes (UKNSC, 2008).
Aim
The purpose of the current study was to present a national overview of current practice and standards, to identify which professionals were performing the NIPE, the percentage of babies examined by midwives, the percentage of midwives trained to perform NIPE, and the criteria for midwives' examinations. Secondary objectives were to identify current standards with respect to the identification and management of babies at risk of developmental dysplasia of the hip (DDH) and infants at risk of congenital heart disease (CHD).
Methods
A questionnaire was developed by a multi-disciplinary team including midwives, researchers and paediatricians, and was designed to capture data on the number of midwives currently performing the NIPE, unit policies and practices for the NIPE, information to women regarding the NIPE, the number of babies examined by midwives born in either a midwifery-led birth setting (home or birth centre) or in an obstetric unit, and whether NIPE training was included as part of pre-registration midwifery education. Opinions on the value of the NIPE were also sought, as well as attitudes to including NIPE as part of pre-registration education of midwives. The survey tool also aimed to assess compliance with standards and attitudes to the timing of the NIPE and identification and management of babies at risk of DD H and CHD. The survey was anonymous and respondents were not allocated numbers.
The Bristol Online Survey (BOS) tool was used to develop and distribute the questionnaire. Following piloting in three local units, the questionnaire and accompanying letter and instructions underwent some minor modifications to further aid clarity and ease of completion. All heads of midwifery (HoMs) were sent a link to the online tool during the autumn of 2014. This was followed-up by two email reminders to non-responders and a telephone contact. HoMs were invited to forward the survey questionnaire to those individuals within their Trusts who were best placed to supply the information. Data were analysed using the BOS analysis function and via detailed analysis of the data by the chief investigator. Analytical rigour was enhanced via the checking of data by the other investigators.
Ethical approval
Ethical approval was sought and obtained from the University of Hertfordshire Ethics Committee for the School of Health and Social Work.
Findings
Response rate
All NHS Trusts (or equivalents) in England, Wales, Scotland and Northern Ireland were invited to participate. While the overall response rate was 64.3%, only 27.3% and 28.6% of responses were received from Scotland and Wales respectively (Table 1).
| Country | Number of Trusts | Number of responses | |
|---|---|---|---|
| n | % | ||
| England | 131 | 92 | 70.2% |
| Scotland | 11 | 3 | 27.3% |
| Wales | 7 | 2 | 28.6% |
| Northern Ireland | 5 | 2 | 40.0% |
| Overall UK response rate | 154 | 99 | 64.3% |
Identified lead for NIPE
A recommendation of the UKNSC (2008) is that each Trust should have an identified lead for the NIPE programme. Of the respondents, 83.8% (n=83/99) of Trusts (or equivalents) stated that they had an identified lead.
Practitioners performing NIPE
Figure 1 and Figure 2 show which health professionals perform the NIPE for babies born in consultant-led units (Figure 1) and those born in midwifery-led settings (Figure 2). Percentages add up to more than 100, as respondents were able to tick more than one answer. Regardless of the birth setting, in the majority of Trusts more than one professional performed NIPE examinations, the majority of babies being examined by midwives, paediatric SHOs or registrars. Midwives were more likely to perform NIPE for babies born in midwifery-led settings (94.9%) followed by paediatric SHOs (40.4%).
Number of midwives qualified to perform the NIPE
More than 95% of Trusts reported employing midwives qualified to perform the NIPE. Information in relation to both the number of midwives employed and the number of midwives trained to perform the NIPE was available for 91.9% (n=91/99) of these Trusts. Analysis of these data show that overall in the UK, just 13.7% (n=2467/18050) of midwives are qualified to perform the NIPE.
Percentage of babies examined by different professional groups
Estimated data relating to which professional groups performed the NIPE were available for 95.9% (n=95/99) of babies born in a consultant-led unit (Table 2) and for 91.9% (n=91/99) of babies born in a midwife-led setting (Table 3). For babies born in consultant-led units, more than 50% of NIPEs were performed by paediatric SHOs or their equivalent in over half of all Trusts: in more than 21% of these Trusts, midwives performed the NIPE on more than 50% of babies. Comparatively for babies born in midwifery-led settings, midwives performed more than 50% of the NIPEs in more than 70% of Trusts.
| What percentage of total NIPEs are undertaken by each professional group? | Percentage of Trusts reporting | ||||||
|---|---|---|---|---|---|---|---|
| Paediatric senior house officers | Paediatric registrars | Midwives | Consultant paediatrician | GPs | Neonatal nurses | Others | |
| 1-5% | 1.1% | 33.7% | 17.9% | 3.2% | 7.4% | 17.9% | 9.5% |
| 6-10% | 4.2% | 25.3% | 9.5% | 1.1% | 0.0% | 3.2% | 3.2% |
| 11-15% | 2.1% | 7.4% | 7.4% | 0.0% | 0.0% | 2.1% | 1.1% |
| 16-20% | 4.2% | 1.1% | 7.4% | 0.0% | 0.0% | 1.1% | 0.0% |
| 21-25% | 6.3% | 9.5% | 13.7% | 0.0% | 0.0% | 2.1% | 2.1% |
| 26-50% | 24.2% | 5.3% | 20.0% | 0.0% | 2.1% | 5.3% | 1.1% |
| 51-75% | 28.4% | 0.0% | 11.6% | 0.0% | 0.0% | 0.0% | 0.0% |
| 76-100% | 24.2% | 0.0% | 9.5% | 0.0% | 0.0% | 1.1% | 0.0% |
| What percentage of total NIPEs are undertaken by each professional group? | Percentage of Trusts reporting | ||||||
|---|---|---|---|---|---|---|---|
| Paediatric senior house officers | Paediatric registrars | Midwives | Consultant paediatrician | GPs | Neonatal nurses | Others | |
| 1-5% | 14.3% | 31.9% | 7.7% | 1.1% | 8.8% | 16.5% | 3.3% |
| 6-10% | 4.4% | 4.4% | 7.7% | 0.0% | 2.2% | 2.2% | 1.1% |
| 11-15% | 6.6% | 0.0% | 2.2% | 0.0% | 0.0% | 0.0% | 1.1% |
| 16-20% | 4.4% | 0.0% | 1.1% | 1.1% | 0.0% | 0.0% | 0.0% |
| 21-25% | 4.4% | 1.1% | 1.1% | 0.0% | 0.0% | 2.2% | 0.0% |
| 26-50% | 7.7% | 1.1% | 6.6% | 0.0% | 0.0% | 1.1% | 0.0% |
| 51-75% | 7.7% | 1.1% | 16.5% | 0.0% | 0.0% | 0.0% | 1.1% |
| 76-100% | 6.6% | 0.0% | 54.9% | 0.0% | 0.0% | 1.1% | 1.1% |
Trust policies and practices for the NIPE
A total of 94.9% (n=94/99) of Trusts reported having either a policy or a guideline for the NIPE. Information in relation to the criteria for which babies could be examined by midwives was sought. Approximately 50% of Trust policies and/or guidelines had specified criteria for babies on which midwives could perform the NIPE (Table 4). Responses add up to more than 94 as more than one answer could be selected.
| Criteria | n | % |
|---|---|---|
| Healthy newborns following uncomplicated pregnancy and delivery | 86/94 | 91.49% |
| Babies born by caesarean section | 57/94 | 60.64% |
| Term babies born by ventouse and/or forceps | 57/94 | 60.64% |
| Babies born at term regardless of mode of delivery | 56/94 | 59.57% |
| Suitability decided by midwife performing the examination | 49/94 | 52.12% |
| Any baby | 8/94 | 8.51% |
| Suitability decided by a paediatrician | 8/94 | 8.51% |
| Suitability decided by midwife in charge | 5/94 | 5.32% |
| Other | 1/94 | 1.06% |
| Total responses | 327 |
Standards and competencies
The UK NIPE standards and competencies (UKNSC, 2008) require that practitioners performing the NIPE should have an ongoing assessment of their competence by a more senior practitioner and have regular updates. Our survey showed that 71.7% (n=71/99) of Trust policies currently require midwifery staff to undertake regular updates, with the majority requiring this either yearly or every 2 years (Figure 3).
In addition, 37.4% (n=37/99) of Trusts have policies requiring midwives to undertake a minimum number of examinations per month to maintain their competence as NIPE practitioners, with 57% of these Trusts specifying one to two examinations and the remainder between three and 10 per month.
Information to parents
The UKNSC (2008) standards state that parents should receive information about the NIPE during the antenatal period and at the time of the examination. A question relating to this was incorporated into the survey. Completed responses were received from 78 Trusts, of which 92.3% (n=72/78) provided the UKNSC leaflet Screening tests for you and your baby, with the remainder either providing a locally devised leaflet (2.6%, n=2/78) or a combination of the UKNSC leaflet and a locally devised one (3.8%, n=3/78). One Trust included information in the handheld records.
The UKNSC (2008) standards recommend giving both verbal and written information to parents at 28 weeks of pregnancy and prior to the NIPE. In 58.4% of Trusts, written information was given at booking only; 24.6% of Trusts gave written information both at booking and prior to the NIPE, while the remaining 15.6% only reported giving written information postnatally.
Timing and location o f the NIPE
The UKNSC (2008) NIPE standards and competencies stipulate that the NIPE ‘should ideally be performed within 24 hours of birth but definitely within 72 hours’. Our survey showed that with the exception of one Trust, these standards were achieved (Figure 4), the majority before 24 hours of age.
Opinion was sought on the optimum age for performing the NIPE. Approximately 55% of respondents believed that the optimum age for performing the NIPE was between 6-24 hours (Figure 5). Respondents' rationale for the optimum time identified was also requested; the main rationales given were time of discharge or accepted practice (Table 5).
| Reasons for the timing of NIPE | n | % |
|---|---|---|
| Prior to discharge home | 51 | 51.5% |
| Accepted practice | 35 | 35.4% |
| Local policy | 25 | 25.3% |
| To ease pressure on beds | 23 | 23.2% |
| Convenience | 21 | 21.2% |
| Opportunistic | 19 | 19.2% |
| Parental request | 11 | 11.1% |
| According to clinic times | 6 | 6.1% |
| Time suits training needs of staff/students | 2 | 2.0% |
| Other | 35 | 35.4% |
For the 35.4% of respondents who stated ‘other’ reasons for the timing selected, these reasons mainly related to clinical factors such as assessment of the neonate's adaptation to extrauterine life, the detection of cardiac abnormalities, the need to assess infant feeding and the parent-infant relationship.
The UKNSC (2008) recommends that all babies should have a NIPE performed prior to discharge from hospital. This survey found that 46.5% (n =46/99) of Trusts were not always compliant with this standard. Reasons for non-compliance were received from 18 respondents: these ranged from parents ‘not prepared to wait’, ‘time pressures’, parents wanting to go home ‘before 6 hours’ and paediatric workload. Information on where the NIPE was performed was also requested of babies who were discharged prior to examination (Table 6).
| Places where NIPE was performed on babies who were discharged from hospital prior to examination | n | % |
|---|---|---|
| At home by a midwife | 15 | 32.6% |
| At the maternity unit as an outpatient and/or at home by a midwife | 9 | 19.6% |
| At the maternity unit as an outpatient | 4 | 8.7% |
| At a midwife's clinic | 2 | 4.3% |
| At home by a midwife and or at a midwife's clinic | 2 | 4.3% |
| Other (includes a combination of the following: at home, at a clinic, at the maternity unit as an outpatient or a GP surgery) | 14 | 30.5% |
Screening for developmental dysplasia o f the hip and management of at-risk infants
Screening for DD H is an important component of the NIPE. Current standards recommend clinical assessment using the Barlow and Ortolani tests, combined with selective screening of infants with identified risk factors for DD H or if abnormalities are detected on clinical examination (UKNSC, 2008). However, controversy still exists regarding the role of clinical versus ultrasound screening for DDH, particularly whether ultrasound screening should be selective or universal (UKNSC, 2008; Mahan et al, 2009; Laborie et al, 2013; Lambeek et al, 2013).
This study found that universal screening with ultrasound for DD H was undertaken in 4.1% (n=4/98) of responding Trusts, with 96.8% (n=91/94) of the remaining Trusts using a selective approach. Selective ultrasound should be performed where there is a family history of hip problems in early life, if the fetus was in the breech position at or after 36 completed weeks of pregnancy or at birth, and in multiple births if one of the babies was in the breech position (UKNSC, 2008). Information on the criteria used for offering selective ultrasound was requested (Table 7). The results show that many Trusts used a number of criteria in addition to those specified by the UKNSC (2014), and 3.3% had no referral pathway for babies with risk factors. Percentages add up to more than 100 as respondents were asked to tick all that apply.
| Criteria for selective ultrasound screening | n | % |
|---|---|---|
| Breech presentation at birth | 90 | 95.7% |
| First-degree relative with dislocated hips | 86 | 93.5% |
| Breech from 36 weeks' gestation but cephalic at birth | 70 | 76.1% |
| First-degree relative with other hip problems from infancy which required treatment | 56 | 60.9% |
| Fixed talipes | 52 | 56.5% |
| First-degree relative with ‘clicking’ hips | 27 | 29.3% |
| Oligohydramnios | 22 | 23.9% |
| Multiple births | 19 | 20.2% |
| Wider family member with dislocated hips | 17 | 18.5% |
| Wider family member with other hip problems from infancy which required treatment | 13 | 14.1% |
| Other congenital abnormality | 14 | 14.9% |
| Intrauterine growth retardation | 5 | 5.4% |
| Caesarean section | 1 | 1.1% |
| Female baby over 4 kg at birth | 6 | 6.4% |
Screening for congenital heart disease and management of at-risk infants
Screening for CHD is an integral part of the NIPE programme (UKNSC, 2008), with current standards recommending clinical assessment within 24 hours to include auscultation for murmurs and referral if abnormalities are detected. While the use of pulse oximetry (PO) as part of the screening programme is currently being evaluated, the UKNSC (2008) advises that PO should only be used as an aid to diagnosis, rather than as a screening procedure, until more robust evidence is available. This study found that 35.4% (n=35/99) of Trusts use PO, and the majority (80%, n=28/35) use this as part of the overall screening process for CH D (Table 8).
| Use pulse oximetry for: | n | % |
|---|---|---|
| All babies as part of the newborn and infant physical examination | 28 | 80.0% |
| Babies at risk of CHD/requiring neonatal observations | 6 | 17.1% |
| Other: only babies examined by paediatricians | 1 | 2.9% |
Trusts that routinely use PO as part of the NIPE programme were asked to state the age of the baby when PO is performed. Responses were received from 28 Trusts. The majority (53.6%, n=15/28) performed PO at the same time as they undertook the NIPE (Table 9).
| Pulse oximetry takes place: | n | % |
|---|---|---|
| As part of the newborn and infant physical examination | 15 | 53.6% |
| Between 4-6 hours old | 2 | 7.1% |
| Between 6-12 hours old | 2 | 7.1% |
| Between 12-24 hours old | 2 | 7.1% |
| Any time prior to discharge | 4 | 14.3% |
| Other e.g. 2 hours old, 6-24 hours old | 3 | 10.7% |
We asked Trusts that used PO as a routine part of the NIPE if they felt it had increased the detection rate for CHD, and 28.6% (n=8/28) of respondents perceived that it had. Of the Trusts which used this test, five cited examples where the use of PO had resulted in babies with CH D being identified, who otherwise would have been overlooked on clinical assessment only. One Trust referred to the outcome of a local PO study that showed improved detection for CH D following the introduction of PO.
Trusts not including PO as part of their screening programme for CHD were asked if they had plans to introduce it over the next year, with 23.4% (n=15/64) reporting that they did have such plans. A quarter of Trusts (25%, n=16/64) stated that they were awaiting national guidance or further evidence, while 48.4% (n=29/64) did not know or did not have any plans to introduce it.
Oxygen saturation criteria indicating cardiac abnormality
Information on the level of oxygen saturation that was considered abnormal was received from 57.6% (n=57/99) of the Trusts, which were either using PO as a screening tool or an aid to diagnosis for CHD (Table 10).
| Oxygen saturation criteria | n | % |
|---|---|---|
| Below 95% | 25 | 43.9% |
| More than 3% difference between pre- and post-ductal saturation | 13 | 22.8% |
| Below 92% | 6 | 10.5% |
| Below 90% | 4 | 7.0% |
| Less than 3% difference between pre- and post-ductal saturation | 1 | 1.8% |
| Don't know | 4 | 7.0% |
| Others e.g. below 94% on 2 occasions, more than 2% difference between pre- and post-ductal saturation | 4 | 7.0% |
Management of cardiac murmurs
Responses were received from 100% of Trusts (n=99/99) on their subsequent management of babies if a cardiac murmur was identified. The usual management comprised either referral to paediatric registrar or performing PO (Table 11). Answers add up to more than 99 as multiple answers could be selected.
| Management of murmur | n | % |
|---|---|---|
| Examination by paediatric registrar or consultant | 89 | 89.9% |
| Pulse oximetry | 50 | 50.5% |
| Outpatient follow-up | 34 | 34.3% |
| Upper and lower limb blood pressure measurement | 34 | 34.3% |
| Echocardiogram | 26 | 26.3% |
| Electrocardiogram | 24 | 24.2% |
| Further auscultation by the same examiner. If murmur absent, no follow-up | 11 | 11.1% |
Additional comments were received from 11 Trusts. These comments related to triggers for further investigations if initial investigations were normal.
Discussion of health issues
The provision of health-care information and the opportunity for discussion with parents is an important part of the NIPE programme. In our survey, 68.7% (n=68/99) of Trusts reported that a discussion on health issues was undertaken routinely. The seven respondents who ticked ‘other’ stated that the discussion of health issues depended on whether the NIPE was performed by a midwife or a doctor, with midwives being more likely to include discussion on health issues. The following quote illustrates a respondent's views:
‘Always if the exam is performed by a midwife—not convinced that paeds SHOs are so consistent with this—health education is documented poorly if the exam is done by an SHO (that is my impression—not yet confirmed by audit).’
Table 12 shows which health-care issues were usually discussed, with the majority of respondents citing feeding, elimination, reducing sudden infant death syndrome (SIDS), jaundice and signs of ill health.
| Issue | n | % |
|---|---|---|
| Feeding | 81 | 81.8% |
| Elimination | 75 | 75.8% |
| Reducing risk of sudden infant death syndrome | 72 | 72.7% |
| Jaundice | 71 | 71.7% |
| Signs of ill health | 65 | 65.7% |
| Umbilical care | 57 | 57.6% |
| Skin care | 50 | 50.5% |
| Sleeping | 50 | 50.5% |
| Follow-on care | 49 | 49.5% |
| Baby's weight | 46 | 46.5% |
| Room temperature | 45 | 45.5% |
| Crying | 32 | 32.3% |
| Immunisations | 32 | 32.3% |
| Nappy area care | 32 | 32.3% |
| Cutting nails | 24 | 24.2% |
| Travelling/car seats | 22 | 22.2% |
| ‘Tummy time’ | 22 | 22.2% |
| Bathing | 20 | 20.2% |
| Other | 17 | 17.2% |
Value of the NIPE
Our results show that the NIPE is highly valued as a screening tool and, for each question, more than 80% of respondents rated it as either good or excellent (Figure 6).
Discussion
The NIPE, or detailed examination of the newborn, is ‘universally accepted as good practice’ (Hall, 1999: 619), with current national standards mandating that all infants should have a detailed physical examination within 72 hours, ideally within 24 hours (Hall and Elliman, 2003; NICE, 2006; UKNSC, 2008).
The purpose of the NIPE is threefold: the provision of health education, parental reassurance and screening for rare abnormalities including CHD, DDH, undescended testes and congenital cataracts (Hall and Elliman, 2003; UKNSC, 2008). The impetus for midwives to develop their practice in this area was stimulated by pressure on junior doctors' working hours, combined with the reduction in postpartum stay and the drive to improve continuity in addition to developments in midwifery-led care. The findings and recommendations of the EMREN study (Townsend et al, 2004) should have resulted in a major change in practice in relation to the professionals who perform the NIPE as well as standards for NIPE. Given the important findings of Townsend et al (2004), together with successive maternity policy recommendations demanding improved quality and cost-effectiveness, it would be expected that by now significantly more midwives would be performing the NIPE.
In contrast to the findings of Hayes et al (2003), which reported that 31% of units had at least some babies examined by midwives, our survey showed that 95% of Trusts now have midwives who perform the NIPE. Nevertheless, we found that the overall numbers of trained midwife NIPE practitioners across the UK was very low, at 13.7%. The reason why so few midwives are trained to perform the NIPE requires urgent investigation given the reported benefits to parents and babies, the drive to develop a personalised service, the benefits of continuity as well as the promotion and expansion of midwifery-led care.
A concern raised by our findings is that while only 13.7% of midwives are trained NIPE practitioners, midwives are performing more than 50% of NIPEs for babies born in consultant-led settings in 21% of Trusts. In addition, midwives are performing more than 50% of the NIPEs in more than 70% of Trusts with midwifery-led birthing facilities. These findings contrast with the survey of Hayes et al (2003), who estimated that midwives performed only 2% of NIPEs. Our findings imply that a limited number of midwives are examining a large number of babies, and not only those infants born to mothers on their caseload or otherwise known to them. This practice could have a negative impact on maternal satisfaction; according to Townsend et al (2004), maternal satisfaction was significantly associated with the provision of continuity. Notwithstanding the potential impact on maternal satisfaction, these practices would conflict with the arguments for developing midwives' role in this area, which centre on the provision of continuity and total/holistic care to women, as well as facilitating autonomous midwifery practice (Rogers et al, 2003). In the study by Rogers et al (2003), midwives reported two main benefits of performing the NIPE: enhanced job satisfaction and improved understanding of the baby. Enhanced job satisfaction was directly related to continuity of care as well as the ability to provide ‘total’ care. Midwives in this study welcomed developing their practice to include this role, providing it did not detract from their core responsibilities as midwives and it enhanced their ability to provide total care to women. However, midwives expressed concern about being ‘pressurised’ into doing the NIPE, or being ‘dumped on’.
‘Our findings suggest that midwives are being used to Lighten the Load on paediatricians… This may impact not only on maternal satisfaction but also on midwifery satisfaction, workload and workforce retention’
In the study by Bloomfield et al (2003b), paediatricians cited that the main benefit for them of midwives doing the NIPE was to assist with their workload. Our findings suggest that midwives are being used to lighten the load on paediatricians, given that so many babies are being examined by the small number of trained midwives. This may impact not only on maternal satisfaction but also on midwifery satisfaction, workload, workforce retention and other midwives' motivation to undertake the NIPE training or use their skills for NIPE following training. This warrants deeper investigation.
In accordance with national standards (UKNSC, 2008), 83.8% of Trusts had an identified lead for NIPE and 94.9% of Trusts had written guidelines. More than 50% of these guidelines had specified criteria for midwife examinations, with 40% prohibiting midwives undertaking the NIPE for babies born by operative delivery. Given the benefits and the improved quality of midwives' examinations compared to junior doctors (Bloomfield et al, 2003a; 2003b), the rationale for restricting the criteria for midwives' examination could be explored and UKNSC guidance on this issue may support standardising practice.
In accordance with UKNSC (2008) standards, 92.3% of responding Trusts provide written information to parents, with the majority using the UKNSC leaflet Screening tests for you and your baby. However, in contrast to the UKNSC standards stipulating that verbal and written information should be given to parents at around 28 weeks and prior to the newborn examination, we identified that in the majority of Trusts (57.7%, n=45/78), parents are currently given this information at booking, with only 15.8% of Trusts reporting that they provide this information in the postnatal period. Taking into consideration concerns about information-overload for women at booking (Stapleton, 2004; National Collaborating Centre for Women's and Children's Health, 2008; NICE, 2013), combined with the importance of aligning information with the timing of the NIPE, we recommend that Trusts review their policies for providing women with this information at the times recommended by the UKNSC (2008).
The UKNSC (2008) states that the NIPE should ideally be performed within 24 hours of birth; however, there is no optimum time and this would vary for the different components of the examination. The evidence-base to support the timing of the NIPE is limited; however, in a review of the evidence, Green and Oddie (2008) argue that the NIPE should be performed after 24 hours to enable some of the physiological changes to have occurred in the cardiovascular system which would improve detection rates of CHD. In our study, the NIPE was performed for the majority of infants before 24 hours, and approximately 55% of respondents believed that this was the optimum time to perform the NIPE. The reasons cited relate to timing of discharge or accepted practice. A significant proportion of respondents (35%) reported that the detection of cardiac abnormalities, the need to assess infant feeding and the parent-infant relationship should be critical factors in determining the optimum timing. Nevertheless, there is a general consensus in the literature that all babies should have the NIPE performed prior to discharge, and the timing of discharge often dictates when it is performed. These views are informed by concerns about the NIPE not being performed in a timely manner in the community, or babies requiring readmission if problems are detected (Green and Oddie, 2008; UKNSC, 2008). In our survey, nearly half of all Trusts reported discharging babies before the NIPE was performed, citing parents being ‘not prepared to wait’, ‘time pressures’, and paediatric workload as the main reason for this. Our study identified that for babies discharged home without the NIPE, the examination was performed either by a midwife at home or as an outpatient. Given the importance of the NIPE, further investigation into the systems and processes for ensuring all babies discharged from hospital without the NIPE performed is required to ensure that it is performed in accordance with national standards (UKNSC, 2008).
DD H remains a major cause of childhood morbidity, affecting 0.8 to 1.6 per 1000 infants, with more recent studies suggesting significantly higher rates of 1.5/1000 and 20/1000 live births (Sewell and Eastwood, 2011; Woodacre et al, 2014). The wide variation in the incidence of DD H reported relates to both the timing of the diagnosis as well as the methods used to make the diagnosis (Sewell and Eastwood, 2011; Woodacre et al, 2014). Clinical examinations using the Ortolani and Barlow tests are the primary methods used and universal screening with these methods was recommended in 1969 (Standing Medical Advisory Committee and the Standing Nursing and Midwifery Advisory Committee, 1986). In a review of the evidence, the Ortolani and Barlow tests have a sensitivity and specificity of 70%-98% and 84%-99% respectively (Woodacre et al, 2014). Concerns about the sensitivity and reliability of the clinical examination have increased interest in the use of ultrasound as both a primary and secondary screening tool. According to Woodacre et al (2014), ultrasound scanning (USS) is the gold standard with a sensitivity of 100%; nevertheless, debates about its cost-effectiveness continue (Elbourne et al, 2002; Green and Oddie, 2008; Sewell and Eastwood, 2011; Woodacre et al, 2014). The revised UKNSC (2014) standard recommends selective USS screening based on identified risk factors and a positive clinical screen result. We identified that only 4% of Trusts offer universal USS, while 97% of Trusts follow the selective screening programme. The revised standards identified the following risk factors for selective USS screening: babies with a positive family history of infants with hip abnormalities, babies presenting or delivered in the breech position, and all infants in the case of a multiple births if any of the babies presented or delivered in the breech position (UKNSC, 2014). For units that used other criteria the advice was:
‘For some other conditions, the evidence of a strong correlation with DDH is… suggestive. These include congenital talipes calcaneovalgus, metatarsus adductus, torticollis, oligohydramnios and a high female birth weight. For units which are currently using these as risk factors we do not suggest abandoning them.’
This advice may account for the variation between Trusts in the criteria used for selective USS in our survey. Further consideration is needed as to whether this variation can be justified given concerns around cost-effectiveness and equity in relation to service provision.
CHD remains a significant cause of infant mortality, affecting 4-10 babies per 1000 live births (Ewer et al, 2012). Early detection is critical to improving both survival and morbidity rates for affected infants. Currently, screening for CHD comprises mid-trimester ultrasound and clinical assessment as part of the NIPE screening programme. These screening tests combined fail to detect 25-30% of infants with critical heart defects and nearly 80% of infants with obstructive left heart defects (Ewer et al, 2012). The cost-effectiveness of using PO as part of the screening process was evaluated by Ewer et al (2012). This review showed that in asymptomatic infants, overall PO had a sensitivity of 75.0% (95% CI 53.3% to 90.2%) for critical cases of CHD and 49.1% (95% CI 35.1% to 63.2%) for combined critical and serious cases. Other important findings included the acceptability of PO to parents and professionals and the fact that additional problems were identified in the 27% of babies who had false-positive results for CHD, but may have other complications such as sepsis. The findings of this review have prompted the UKNSC to undertake a pilot study to identify the cost-effectiveness of introducing PO as part of national standards. Currently, there are 15 Trusts participating in the pilot study (UKNSC, 2015); however, in our survey, 35 Trusts were using it as part of the NIPE, with 28 of these Trusts using it as an adjunct to the clinical examination. The remainder performed PO for all babies with identified risk factors for CHD, or babies having regular neonatal observations. We also identified variable practices between Trusts in relation to the age of the baby when PO was performed, as well as oxygen saturation levels used to suggest an abnormal result; this indicates the need for national standards. Similarly, the variation found in our survey in relation to the management of babies where cardiac murmurs were heard during the NIPE provides additional evidence to support the review of national standards (UKNSC, 2008).
The NIPE provides an ideal opportunity for health education and advice to new parents on their infant's physical and emotional wellbeing (Hall and Elliman, 2003; Townsend et al, 2004), which has been shown to be highly valued by parents (Townsend et al, 2004). Townsend et al (2004) showed that maternal satisfaction was closely related to a discussion on health issues. Mothers who reported that health issues had been discussed during the examination were less than half as likely to report low satisfaction (crude OR=0.43, 95% CI 0.30-0.60, n=645). Our findings are reassuring, with more than 68% of Trusts reporting that a discussion on health issues was an integral part of the NIPE. As with the findings of Townsend et al (2004), the main issues discussed include feeding, elimination, prevention of sudden infant death, jaundice and signs of ill health. Important health issues that NIPE practitioners were less likely to discuss included crying, ‘tummy time’, infant bathing, use of car seats and immunisations. Given the importance of these issues, together with the number and range of professionals providing information to parents in the perinatal period, we recommend that standards in relation to the provision of health information be reviewed. A review should include not only which topics to address, but also how and when information is given and who provides it. This would ensure that all parents receive consistent evidence-based information addressing key issues that can negatively impact on newborns' physical and emotional development. Our survey showed that nearly a third of Trusts do not discuss signs of ill health as part of the NIPE. This is of concern given the known limitations of the examination (Hall and Elliman, 2003; Green and Oddie, 2008; Ewer et al, 2012). However, despite the limitations of the NIPE, in concurrence with the findings of Hayes et al (2003), the NIPE remains valued by practitioners, with the majority rating the NIPE as good to excellent as a screening tool for all the component parts.
Limitations
The authors have acknowledged limitations inherent in this study; not least of which was the limited response from Wales, Northern Ireland and Scotland. Furthermore, respondents were unable to provide information in relation to whether babies with identified risk factors for DD H and CHD did receive follow-up appointments in accordance with UKNSC standards, and therefore compliance with these important standards could not be reported on. A further limitation is that information on the follow-up and management of babies with possible ocular abnormalities and maldescent of the testes was not requested.
In general, only estimated data were available regarding which professionals undertake the NIPE and the percentage of NIPEs performed by the different professionals, which many limit the accuracy of these findings. The implementation of the bespoke IT screening management system, the NIPE Screening And Reporting Tools (SMART), should enable the provision of more robust information and address some of the data quality issues identified. Finally, the results are based on self-reporting, therefore non-responders also need to be taken into consideration.
Conclusions
In summary, despite the findings and recommendations of the EMREN study of 2004 (Townsend et al, 2004), our findings suggest that only a small minority of midwives are currently undertaking the NIPE. Those who do conduct this examination, however, are examining babies in far greater numbers beyond the extent of their work allocation or caseload, highlighting a lack of continuity of carer for mother and baby. The low number of NIPE-trained midwives is of concern and the reason for this warrants further investigation.
Findings of this study also indicate scope for improvement in the timing, quality and consistency of information to parents and the processes for following-up those babies discharged home prior to the NIPE. Wide variations were found in the use of USS for DD H and PO for the detection of cardiac anomalies. Despite the limitations of this study, a lack of consistency across Trusts in the UK is clearly evident, suggesting the need for further research, which may in turn prompt the development of more robust guidelines for practice and improved screening for neonates.