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EDITORIALS: D M B Hall The role of the routine neonatal examination BMJ 1999; 318: 619-620 [Full text]

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Neonatal examination - time for a change

David Walker   (8 March 1999)

Broader criteria should be used to evaluate the role of neonatal examination

S P Leung   (10 March 1999)

Neonatal examination - time for a change 8 March 1999
David Walker Send response to journal: Re: Neonatal examination - time for a change	I read with interest and concur with DMD Hall`s editorial on the role of routine neonatal examination. As a Senior House Officer in a neonatal unit with over seven thousand births a year, I can confirm needless hold-ups in mother and child discharge due to heavy workload and inevitable delays. My crude, hurriedly acquired examination skills often act as a front and do little to reassure me, that all is well with the child I am examining. Enquiries about feeding, the behaviour of the child and even the contents of its nappies give me greatest confidence in my clinical decision making. Most valuable time during neonatal checks is spent talking about educational aspects of childcare and what a new mother can expect from her child in the coming weeks. Medical examination can, I believe, be deferred to a Midwife with positive advantages for mother and child. The established relationship between Midwife, mother and child, should be built on to create a seamless flow of reassuring advice where the clinical examination would be seen as part of that process and not a separate issue. Where high sensitivity and specificity exist for parts of the clinical examination, protocols should continue to be used to ensure correct management. Having witnessed first hand the successful contribution made by Advanced Neonatal Nurse Practitioners in the unit in which I work, I feel that clinical examination skills if properly taught, can be undertaken by other medical personnel and doctors should not regard this as a challenge to their position as clinician. If neonatal examination is recognised as a blunt tool in the screening for childhood diseases, then we should not be afraid redefine our goals and alter our clinical practice, to ensure a better quality of care and education. David Walker Senior House Officer Neonatal Medicine department Womens Centre John Radcliffe Hospital Headington OXFORD
Broader criteria should be used to evaluate the role of neonatal examination 10 March 1999
S P Leung, Visiting Paediatrician, Hong Kong Baptist Hospital Hong Kong Baptist Hospital, 222 Waterloo Road, Kowloon, Hong Kong Send response to journal: Re: Broader criteria should be used to evaluate the role of neonatal examination	Hall (1) concluded from the paper by Glazener et al (2) that having two routine neonatal examinations is no better than one. Three issues must be considered. Firstly, the conclusion was partly based on the findings by Glazener et al (2) that despite more babies who were examined twice attended orthopaedic outpatient clinics for suspected congenital dislocation of the hip, there was no significant difference in the number of babies who required active management. However, the number requiring active management in both groups were small ( 12 vs 15), and the study was unlikely to have sufficient power to detect differences in the outcome between the two group even if they existed. Secondly, early detection of dysplastic hips might have been managed satisfactorily by measures such as double nappies, hence reducing the number subsequently requiring active management. Thirdly, in many countries, neonatal examination provides the only opportunity for a paediatrician to detect abnormalities which might otherwise be missed by a general practitioner. Hence, a second examination may minimise the risk of an important diagnosis being missed. Applying traditional criteria for good screening tests, Hall (1) also doubted whether neonatal examinations are really useful at all. However, neonatal examinations are different from many screening tests. Firstly, most parents would like to receive either counselling on minor problems or reassurance that their newborn babies are normal. Since the health professionals must examine the baby before such explanations or reassurance can be given and that the time taken to perform a proper neonatal examination is probably no more than five minutes, abolition of routine neonatal examinations is unlikely to save much time. Secondly, neonatal examination may occasionally detect initially unsuspected serious conditions such as coarctation of the aorta or diaphragmatic hernia, prompt treatment of which may greatly improve prognosis. Thirdly, apparently minor abnormalities may indicate serious underlying abnormalities (e.g. facial capillary haemangiomas may suggest underlying intracranial arterio-venous malformation); minor dysmorphic features may hint the presence of chromosomal abnormalities or dysmorphic syndromes. These may prompt active treatment or close monitoring for the development of complications. The role of neonatal screening should therefore be evaluated using broader criteria than the Wilson's criteria for screening. Furthermore, much stronger evidence is required to convince the public to withdraw an existing neonatal examination programme than to introduce a new screening programme. The decision to abolish neonatal examinations cannot be taken lightly. Reference 1) Glazener CMA, Ramsay CR, Campbell MG, Booth P, Duffty P, Lloyd DJ. Neonatal examination and screening trial (NEST): a randomised, controlled, switchback trial of alternative policies for low risk infants BMJ 1999; 318:627-632 ( 6 March ) 2) Hall, D M B. The role of the routine neonatal examination. BMJ 1999; 318: 619-620