The hours after birth are a blur for parents, and behind that blur is a quiet, structured set of clinical assessments. Knowing what the paediatrician or neonatologist is checking — and what they're checking for — turns those moments from mysterious procedures into useful information. For a wider view, see our complete guide to child health.
The NIPE — Newborn and Infant Physical Examination
In the UK, the NIPE is offered to every baby within 72 hours of birth (ideally in the first 24 hours), with a repeat at 6–8 weeks via the GP. It's a structured top-to-toe check, but four areas get particular attention because each is a condition where early treatment changes the outcome dramatically.
Heart
The examiner listens with a stethoscope at four cardiac auscultation points and palpates the femoral pulses. They're listening for murmurs — extra sounds that might indicate a structural problem.
A murmur in a newborn doesn't automatically mean disease. Innocent (flow) murmurs are common as the foetal circulation rearranges itself: the ductus arteriosus closes, the foramen ovale flap seals, pulmonary pressures drop. Many "murmurs of the newborn" are simply this transition.
Pathological murmurs prompt further assessment, usually starting with pre- and post-ductal pulse oximetry (a screen now routine in many UK units) and progressing to echocardiogram if needed. Significant congenital heart disease affects around 8 in 1,000 babies. The specific lesions that the NIPE plus pulse oximetry are designed to catch — duct-dependent lesions like coarctation of the aorta and transposition of the great arteries — are time-critical because babies with these conditions deteriorate when the duct closes in the first days of life.
The examiner also feels for the femoral pulses. Weak or absent femoral pulses point toward coarctation of the aorta and are a key non-auscultatory sign.
Hips
Developmental dysplasia of the hip (DDH) is a spectrum, from mild laxity through subluxation to frank dislocation, where the femoral head doesn't sit correctly in the acetabulum. Untreated DDH causes long-term joint problems — early arthritis, limp, leg-length difference. Caught early, a Pavlik harness (worn for 6–12 weeks) usually corrects it without surgery.
Two clinical tests:
- Ortolani manoeuvre: with the baby's hips flexed and abducted, the examiner gently lifts the femur — a "clunk" indicates a dislocated hip relocating into the socket.
- Barlow manoeuvre: with the hips adducted, gentle posterior pressure tries to dislocate a reducible hip.
The screen also picks up risk factors that prompt ultrasound assessment even in the absence of a positive examination: breech presentation in the third trimester, family history of DDH (parent or sibling), and persistent foot deformity. Ultrasound at around 6 weeks is the gold standard in babies under 4–6 months because the femoral head is still cartilaginous and doesn't show on X-ray.
Eyes
The red reflex is checked with an ophthalmoscope held about 30 cm from the baby's eyes. A normal eye reflects red — the same effect that produces red-eye in flash photography. An absent or white reflex (leukocoria) can mean:
- Congenital cataract — vision develops in the first months of life, and an undiagnosed cataract during this window causes amblyopia even if removed later. Surgery in the first weeks gives the best visual outcome.
- Retinoblastoma — a rare eye tumour (around 50 cases a year in the UK) where early detection has a major impact on both eye-saving and life-saving outcomes.
- Less commonly, retinal detachment, vitreous haemorrhage, or other intraocular pathology.
A baby with an abnormal red reflex is referred urgently to paediatric ophthalmology.
Testes (in Male Babies)
Both testes should be palpable in the scrotum at the NIPE. Undescended testis (cryptorchidism) affects around 3–5% of term male babies and 30% of preterm boys. About 75% of undescended testes descend spontaneously by 6 months — those that haven't are typically referred for surgical correction (orchidopexy) at around 12 months. Persistent undescent matters because of subfertility and increased testicular cancer risk in later life.
The Heel-Prick (Newborn Bloodspot Screen)
At around day 5 (sometimes day 6–8), the midwife takes a small sample of blood from the baby's heel. Four to six spots fill a card that's posted to the regional newborn screening laboratory. The screen covers nine conditions — all treatable, all causing significant harm if missed:
- Sickle cell disease
- Cystic fibrosis
- Congenital hypothyroidism
- Phenylketonuria (PKU)
- Medium-chain acyl-CoA dehydrogenase deficiency (MCADD)
- Maple syrup urine disease (MSUD)
- Isovaleric acidaemia (IVA)
- Glutaric aciduria type 1 (GA1)
- Homocystinuria (HCU)
Results take around six weeks. You'll only hear back if there's a positive screen — and a positive screen is not the same as a confirmed diagnosis; it triggers a confirmatory test, often a repeat bloodspot or a specialist clinic appointment.
The heel-prick is uncomfortable but brief. Feeding the baby during the test, keeping the foot warm beforehand, and skin-to-skin contact all measurably reduce distress.
Newborn Hearing Screening
Before discharge — or in the first few weeks at home, depending on the unit — every baby is offered the automated otoacoustic emission (AOAE) test. A small probe sits in the ear canal, plays a clicking sound, and measures the response from the cochlea. The test takes a few minutes per ear and is done while the baby is calm or asleep.
A "refer" result on the first attempt does not mean hearing loss. Most refers are caused by amniotic fluid still in the ear canal, background noise, or a fidgety baby. Babies who refer are offered repeat AOAE and, if needed, an automated auditory brainstem response (AABR) test, which is slightly more involved and held in audiology.
True congenital hearing loss affects around 1 in 1,000 babies. Early detection — within the first weeks — and intervention by 3–6 months gives the best language development outcomes.
The Rest of the General Examination
Alongside the four NIPE focal areas, the examiner runs through:
- Head and fontanelles — shape, size, sutures, and tension
- Face and palate — checking specifically for cleft palate, which can be missed because the soft palate isn't visible without a torch and a tongue depressor
- Spine — for skin lesions, dimples, hair tufts, or sacral pits that could mark spina bifida occulta
- Abdomen — palpating for organomegaly
- Genitals — beyond testicular descent, looking at the urethral position (hypospadias) and overall structure
- Tone, reflexes, and movement symmetry — Moro, palmar grasp, suck, and asymmetry between the limbs
- Femoral pulses, perfusion, colour
- Weight, length, and head circumference
Parents are usually present for the whole examination and absolutely should ask questions as it's happening — the examiner is talking through findings as they go, but the explanations are quick and easy to miss in the early postnatal fog. If something wasn't clear, ask. The notes get written up immediately and the explanation given verbally is what you'll remember most clearly.
Key Takeaways
The Newborn and Infant Physical Examination (NIPE) happens within 72 hours of birth and focuses on four areas where early detection genuinely changes outcomes: heart (murmurs and congenital heart disease, which affects roughly 8 per 1,000 babies), hips (Ortolani and Barlow tests for developmental dysplasia), eyes (red reflex for cataracts and retinoblastoma), and testicular descent in boys. The day-five bloodspot screen covers nine treatable conditions. The hearing screen uses an automated probe in the ear and takes minutes. A second NIPE follows at 6–8 weeks.
