Neonatal Examination OSCE — NIPE Head-to-Toe Newborn Check with Red Flags

Introduction

The Newborn and Infant Physical Examination (NIPE) is a structured screening examination performed within 72 hours of birth and again at 6-8 weeks. In the OSCE it tests your ability to examine a newborn systematically, identify congenital abnormalities, and communicate findings sensitively to parents.

NIPE Overview — What It Screens For

These four are the mandatory NIPE targets — remember them as ETHS: Eyes, testes, Hips, Sounds (heart).

Systematic Head-to-Toe Examination

General Observation

• Colour: pink centrally (acrocyanosis of hands and feet is normal in the first 24 hours)
• Tone: good spontaneous movement; hypotonia = concern
• Cry: strong, vigorous
• Gestational age appearance: compare to stated gestation

Head

• Fontanelles: anterior (diamond-shaped, soft and flat); posterior (smaller, closes by 8 weeks)
• Bulging fontanelle = raised ICP (meningitis); sunken = dehydration
• Sutures: overriding is normal immediately after birth; craniosynostosis = premature fusion
• Caput succedaneum: diffuse scalp oedema (crosses suture lines, resolves quickly)
• Cephalhaematoma: subperiosteal collection (does NOT cross suture lines)
• Head circumference: plot on centile chart

Face

• Dysmorphic features: low-set ears, single palmar crease, upslanting palpebral fissures (trisomy 21)
• Cleft lip (visible) — refer; cleft palate requires palpation of hard and soft palate
• Eyes: symmetrical, no discharge; test red reflex bilaterally

Eyes — Red Reflex

Mouth and Palate

• Palpate the hard and soft palate with a gloved little finger — submucous clefts are easily missed visually
• Epstein's pearls: white cysts on palate (benign, resolve spontaneously)
• Natal teeth: present in 1:2000; refer if loose (aspiration risk)

Neck

• Sternocleidomastoid mass: sternocleidomastoid tumour (torticollis) — physiotherapy
• Webbing: Turner's syndrome

Chest and Heart

• Inspect: shape, respiratory rate (normal 30-60/min), recession, grunting
• Auscultate heart: rate, rhythm, murmurs
• Murmurs: most are innocent; note timing, character, radiation
• Femoral pulses: absent or weak femoral pulses suggest coarctation of the aorta

Abdomen

• Shape: distension may indicate obstruction or organomegaly
• Umbilical cord: normally dries and separates by day 7; periumbilical erythema = omphalitis
• Organomegaly: palpate liver (normal edge 1-2 cm below costal margin); spleen and kidneys
• Hernias: umbilical hernias are common and usually close by age 3-4

Genitalia and Anus

Hips — Barlow and Ortolani

Risk factors for DDH: female sex, breech presentation, family history, oligohydramnios. Positive tests require urgent hip ultrasound.

Spine and Skin

• Run fingers along the full spine: sacral dimple with skin tag or hair tuft over the spine = refer (occult spinal dysraphism)
• Mongolian blue spot (common in darker skin tones — benign and normal, document to avoid later confusion with bruising)
• Port wine stain: if trigeminal distribution = Sturge-Weber syndrome

Limbs and Hands

• Count digits: polydactyly, syndactyly
• Single palmar crease: associated with trisomy 21 but also seen in 4% of normal neonates
• Talipes equinovarus: fixed or positional; refer orthopaedics if fixed

Presenting the Neonatal Examination to Parents

• "Your baby looks well overall. I have examined her from head to toe and everything is normal."
• Address any findings sensitively and explain what they mean
• Explain the NIPE targets: "We check four things in particular — the eyes, the heart, the hips, and the testes"
• Document all findings in the Red Book (Personal Child Health Record)

"What are the four mandatory NIPE screening targets?"

Eyes (red reflex for cataracts and retinoblastoma), heart (congenital heart disease), hips (developmental dysplasia of the hip), and in males, testes (undescended testes or cryptorchidism). These four targets are screened at birth and again at 6-8 weeks.

"How do you perform Barlow and Ortolani tests and what do they detect?"

Both tests screen for developmental dysplasia of the hip (DDH). Barlow test: with the hip flexed at 90 degrees, apply gentle downward and lateral pressure — a clunk indicates the femoral head is being displaced out of the acetabulum (dislocatable hip). Ortolani test: from the same position, abduct the hip while lifting the greater trochanter — a clunk as the head reduces back into the acetabulum confirms DDH. A positive result requires urgent hip ultrasound.

"What is leukocoria and what causes it?"

Leukocoria is a white or absent red reflex in one or both eyes on fundoscopic examination. It is a medical emergency: the most serious cause is retinoblastoma, a malignant tumour of the retina that is life-threatening if untreated but curable with early diagnosis. Other causes include congenital cataract, toxocariasis, and persistent hyperplastic primary vitreous. Any absent or white reflex requires same-day ophthalmology referral.

"How do you differentiate caput succedaneum from cephalhaematoma?"

Caput succedaneum is diffuse, pitting oedema of the scalp caused by pressure during delivery. It crosses suture lines, is present at birth, and resolves within 24-48 hours. Cephalhaematoma is a subperiosteal haematoma caused by rupture of periosteal blood vessels. It does not cross suture lines, appears within hours to days after birth, and resolves over weeks to months. Both are benign but must be distinguished.

Related guides: Paediatric History Taking OSCE | Paediatric Developmental History OSCE | Hip Examination OSCE