Brief Report

How Many Physical Exams are Necessary for Low-Risk Newborns?

Source: Glazener CM, et al. Neonatal examination and screening trial (NEST): A randomised, controlled, switchback trial of alternative policies for low risk infants. BMJ 1999; 318:627-631.

Although there is universal agreement that all newborn infants should be screened for physical abnormalities by a complete physical examination, there is little consensus or data concerning how frequently this examination should be performed. The Aberdeen, Scotland, Maternity Hospital has had a longstanding policy of performing two neonatal physical examinations on low-risk newborns—one within 24 hours after birth and a second a few days later, prior to discharge. The need for and value of the second examination was questioned in the hospital. Glazener and colleagues carried out a two-year study that randomized low-risk newborns to receive either one or two neonatal physical examinations. Examinations were performed by hospital-based pediatricians, community-based medical officers, and senior pediatric house officers. Conditions likely to be detected by neonatal screening examinations were classified by the ICD-9 International Classification of Disease. The one-examination group had a total of 4835 newborns, and the two-examination group consisted of 4877 newborns. Significantly fewer abnormalities were diagnosed in the hospital among the one-examination babies (8.3% vs 9.9%). The 1.6% difference had a confidence interval or difference of 0.3-2.7%. The larger number of abnormalities diagnosed at birth was primarily attributable to an excess in suspected hip abnormalities. This resulted in extra referrals to outpatient departments and orthopedic consultations. However, these extra visits did not result in more active management because similar numbers of infants in each group underwent splinting or operations. There was no difference in the number of heart abnormalities between the two groups. Glazener et al conclude that there was no evidence of a net health gain from a policy of two hospital screening examinations. A single complete neonatal physical examination, combined with a repeat examination at 8 weeks of age, has similar results of detecting significant abnormalities as two neonatal examinations.

In the United States, most babies get only one examination in the hospital nursery because of short lengths of stays. This study should be of some reassurance that not many significant abnormalities are likely to be missed.

True statements about neonatal screening physical examinations include all of the following except:

    a. a greater number of abnormalities are diagnosed when two vs. one neonatal exams are performed.
    b. most of the difference between number of abnormalities detected are explained by hip abnormalities.
    c. a greater number of cardiac abnormalities are detected when two examinations are done.
    d. a larger number of hip abnormalities that require orthopedic interventions are found when two examinations are done.