Editorials

The role of the routine neonatal examination

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Papers p 627 others meticulously inspect their newborn genital cataract and other eye defects, submucous cleft
infants,1 but, because health professionals palate, hypospadias, and cutaneous markers of occult
think they can do it better, routine neonatal spinal dysraphism.
examination is universally accepted as good practice.2 Much of the anxiety expressed by many general
Is this really useful and, if it is, should infants be exam- practitioners about examining newborn infants is
ined twice or is once enough? No one has yet been focused on two conditions, heart disease6 8 and
brave enough to address the first question with a congenital dislocation of the hips. The Aberdeen
randomised trial. As to the second, common sense group, like many others, noted that several cases of hip
suggests that a second examination might occasionally dislocation were missed. Screening for congenital
detect a problem missed at the first one, but a study dislocation of the hip is still problematic9—and primary
from Aberdeen now tells us firmly that one is sufficient screening by ultrasound is not the answer. The clinical
(p 627).3 If there are any benefits from a second exam- examination may be too difficult for a screening test, or
ination, they were too small to be detected in a sample intrinsically flawed, but personal observation of exam-
of 10 000 babies, though the study lacked the power ination candidates suggests that poor technique due to
confidently to compare outcomes for congenital dislo- inadequate training is at least partly to blame.
cation of the hip and serious heart disease. The most serious forms of congenital heart disease
Medical staff shortages often delay discharge after usually present within the first few days and demand
childbirth until the baby can be examined. The exam- prompt investigation. The concern is about missing
ination is usually done by junior doctors and is of defects that might present after the baby leaves hospital
uncertain quality. Thus there is increasing interest in and have rapidly progressive symptoms. Unfortunately,
midwives or health visitors doing this job—but nurses even the most expert examiner will miss many cases
insist on adequate training. The need to design a train- since some conditions are not detectable in the early
ing programme is a powerful stimulus to revisit the days of life, before the ductus closes. Perhaps greater
rationale of traditional activities. So what is the awareness among parents and the primary care team
evidence in support of routine neonatal examination? about the need to take non-specific symptoms seriously
Some important anomalies are detected antena- would be a better way of identifying these babies.
tally; some are associated with low birth weight, intra- Many other conditions, notably some metabolic,
uterine growth retardation, or neonatal illness; and hepatic, and neurological disorders, evolve over the early
many are apparent at birth or are noticed within a few weeks of life and are not readily detected on the first
hours by the mother. In all these situations the paedia- day.10 It is therefore important to redefine the role and
trician’s job is to communicate the diagnosis with sen- timing of the neonatal examination and the part played
sitivity4 and explain and plan management. by different health professionals. A midwife trained in
Routine neonatal examination of babies whose neonatal examination could do the initial assessment
mothers believe them to be normal aims to detect and also ensure that screening programmes are
abnormalities that might be missed and, when none properly explained11 12 and could monitor the neonate’s
are found, to provide reassurance. Both the examina- progress during routine visits to the mother.
tion and its individual components are, therefore, a If detection of dislocated hips and heart disease are
form of screening and can be evaluated as such. Other regarded as key outcome measures, robust compari-
possible benefits from this procedure are harder to sons between different approaches to the neonatal
evaluate but may be just as important. They include examination need enormous sample sizes. It may be
providing information and education, recognising and more profitable to compare clinical competence and
supporting parents with mental health problems, and skill acquisition between professional groups and to
preventing postnatal depression.5 evaluate other less tangible outcomes such as the qual-
What are the target conditions and can they be reli- ity of information provided and parental satisfaction.
ably detected? The list is long, but few meet the classic
D M B Hall Professor of community paediatrics
criteria for a screening test. How and with what confi-
Division of Child Health, Sheffield Children’s Hospital, Sheffield
dence can normality be recognised? The experienced S10 2TH
observer first carries out a ‘‘gestalt’’ inspection,6 looking
for evidence of dysmorphic syndromes, atypical behav-
ioural patterns, and signs of acute illness such as
1 McFadyen A. Parent-child relationships from different perspectives. In:
impaired alertness or respiratory problems. Normal Special care babies and their developing relationships. London: Routledge,
patterns of responsiveness and movement are reassur- 1994:9-34.
2 Hall DMB. Health for all children. Oxford: OUP, 1996.
ing, but transient and non-significant abnormalities 3 Glazener CMA, Ramsay CR, Campbell MK, Booth P, Duffty P, Lloyd DJ,
limit the specificity of neurological examination.7 et al. Neonatal examination and screening trial (NEST): a randomised,
controlled, switchback trial of alternative policies for low risk infants. BMJ
Systematic examination may reveal various common 1999;318:627-32.
abnormalities, which are usually not important but 4 Davis H. Counselling families of children with disabilities. In: Davis H,
Fallowfield L, eds. Counselling and communication in health care. Chichester:
worry parents. Examples include minor birth injuries John Wiley, 1991:223-38.
such as cephalhaematoma, fractured clavicle, haeman- 5 Cooper P, Murray L. Prediction, detection, and treatment of postnatal
depression. Arch Dis Childhood 1997;77:97-9.
gioma, preauricular tags, and erythema toxicum. Some 6 Platt WMP. Newborn screening examination (excluding congenital dislo-
BMJ 1999;318:619–20 anomalies must be sought with more care, such as con- cation of the hip). Semin Neonatol 1998;3:61-6.

BMJ VOLUME 318 6 MARCH 1999 www.bmj.com 619

7 Majnemer A, Mazer B. Neurologic evaluation of the newborn infant: 10 Baker A, Hadzic N, Dhawan A, Mieli-Vergani G. Biliary atresia. In: David
definition and psychometric properties. Develop Med Child Neurol TJ, ed. Recent advances in paediatrics. Vol 16. Edinburgh: Churchill Living-
1998;40:708-15. stone, 1998:25-40.
8 Arlettaz R, Archer N, Wilkinson AR. Natural history of innocent heart 11 Seymour CA, Thomason MJ, Chalmers RA, Addison GM, Bain MD,
murmurs in newborn babies: controlled echocardiographic study. Arch Cockburn F, et al. Newborn screening for inborn errors of metabolism:
Dis Childhood Fetal Neonatal 1998;78:F166-70. a systematic review. Health Technol Assess 1997;11:1-95.
9 Dezateux C, Godward S. Screening for congenital dislocation of the hip 12 Davis A, Bamford J, Wilson I, Ramkalawan T, Forshaw M, Wright S. A
in the newborn and young infants. In: David TJ, ed. Recent advances in pae- critical review of the role of neonatal hearing screening in the detection
diatrics. Vol 16. Edinburgh: Churchill Livingstone, 1998:41-58. of congenital hearing impairment. Health Technol Assess 1997;10:1-176.

BMJ introduces a fast track system for papers

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ach year when we revisit the BMJ’s mission and paper, though the speed with which we communicate it
strategy, we aim to improve our services to read- to you will. You will have a decision within 24 hours of
ers, contributors, and reviewers. One step we that meeting. If the decision is to accept the paper then
believe will help is to introduce a formal ‘‘fast track’’ we could normally offer publication within two and a
system for urgent or important papers. Our new fast half weeks of the decision. Exceptions to this schedule
track system begins today. We hope it will attract might occur when a special issue of a journal is
researchers with high quality studies to submit them to planned for a particular date, when the paper arrives at Our fast track
logo
the BMJ, and we hope it will serve readers by helping us the office over a cluster of public holidays such as
to attract better papers. But because fast tracking a Christmas or Easter, or when you want longer than 48
paper is demanding of editorial and reviewers’ time, we hours to make any revisions. If we are to achieve publi-
will focus the service on a very small number of papers. cation within four weeks of registration, however, we
From now on we will be able to offer publication of a will need you to return the revised manuscript within
paper which meets our criteria for fast track review 48 hours of hearing our decision and the proofs within
within four weeks of its registration in our office. In the 24 hours of receiving them.
past we have resisted the idea of fast track publication, To protect other papers from being held up, we will
because we believe all papers we publish are important be selective about which papers to fast track. We would
or interesting and we feared that the time and attention consider papers of exceptional scientific or clinical
consumed by a minority of fast track papers might result importance or papers where there is a public policy
in a ‘‘slower track’’ for others. We have now changed our reason for urgent publication. We are unlikely to fast
mind. In truth, some papers have always been processed track papers because of institutional pressures on the
fast, because of a particular clinical or scientific urgency contributors or because of their eminence. Of the 100
about the message they carry. A recent example was the
or so papers we receive each week, we would expect to
UK Prospective Diabetes Study showing that tight
fast track fewer than one every three or four weeks. If
control of blood pressure reduces morbidity in type 2
yours is to be one of them you will need to convince us
diabetes.1 The publication of this paper was timed to
that a reduction of a few weeks in the time to
coincide with an international conference, which prom-
publication will really make a difference to the years it
ised to be an effective means of disseminating its clinical
has taken to conduct the research and months to write
messages.
it up. The paper will also need to conform in all
We now want to formalise this process and clarify the
respects to our advice to contributors (http://
criteria we use, so that it will be accessible to all our
www.bmj.com/guides/advice. shtml), including a word
potential contributors. In practice we envisage a
limit of 2000 words of text.
partnership between contributors and editors to bypass
Our detailed instructions are on our website. In
the delays inherent in our routine process without com-
promising the quality of peer review. brief, these require that you let us know when the
This means that if you send us a paper with a manuscript will arrive and undertake to be available
request for fast tracking we will undertake to review it for swift revisions and proof reading. Please do not ring
in house immediately, and give you one of three pos- the editors directly, since we cannot give an undertak-
sible answers within 24 hours of its registration in the ing by telephone to fast track a paper we have not seen.
office (or the next working day if it arrives on a Friday). We will evaluate the new system as we introduce it,
We might reject the paper if we feel it is simply not to check that the opportunity costs of fast tracking do
suitable for the BMJ. We might agree that it merits fast not outweigh its benefits. But we hope that it will help
track review, in which case we will send it to reviewers us to provide a fair and transparent channel through
the same day and give you a decision within two weeks. which exceptional research can reach readers as
quickly and reliably as possible. website
Alternatively, we might decide that the paper does not
extra
merit urgent review but that we would like to consider Sandra Goldbeck-Wood Papers editor, BMJ
it in our normal timescale. Instructions on
Roger Robinson Associate editor, BMJ submitting fast
If we agree to fast track your paper we will reserve a track articles
place for it at the next possible editorial committee
meeting, where clinicians, editors, and a statistician www.bmj.com
1 UK Prospective Diabetes Study Group. Tight blood pressure control and
make a final decision about publication. That decision risk of macrovascular and microvascular complications in type 2 diabetes.
will not be influenced by the fast track status of the BMJ 1998;317:703-13. BMJ 1999;318:620

620 BMJ VOLUME 318 6 MARCH 1999 www.bmj.com