Newborn Baby Checks – AGPAR

One of your main concerns when your baby’s born will almost certainly be is he or she OK? As soon as he’s born, your midwife will carry out some basic checks:

• Assessing his colour
• His breathing
• His heart rate
• His movements
• His crying

This test is called the APGAR Test

This is a check which the midwife does at one minute after your baby is born. You may not even notice that the midwife is doing this, and it can be carried out even if you are holding your newborn baby. It is then carried out again after five minutes, and sometimes 10 minutes. Your baby is given a score between 0 and 10.

You may notice the score written down as a figure out of 10. So it may say something like 7/10 and 10/10 meaning that he scored 7/10 at birth and 10/10 at five minutes. A score of 7 or above is deemed acceptable. A baby scoring between 5 and 7 may need some help with breathing. This may involve the midwife giving your baby a vigorous rub, clearing her
nose and mouth of mucus and administering oxygen if necessary. If the birth score is very low, or the five minute score is lower than about 5 or 6, a paediatrician will usually be called to check the baby, or if you’re at home, you may need to transfer into hospital.

Most babies respond well by the second APGAR, and a low initial score is not indicative of poor health.

General initial assessment

This involves the midwife making sure that your baby’s body, face and limbs look normal. The midwife will feel inside the baby’s mouth to check that the palate is complete and there is no sign of a cleft palate. The midwife will also check that there is no problem with the spine and examine fingers and toes and the genitalia and anus.

The midwife will also weigh your baby and may measure your baby’s head and body length.

Examination carried out in the first few days

If you have your baby in hospital, a paediatrician (or perhaps a midwife if they have had special training) will give him a thorough examination before you go home. If you have a homebirth, your GP or a trained midwife will visit you at home to do the examination. The doctor/midwife should explain to you what he/she is doing at each stage of the examination.

The examination will include:

• Examining his skull to check the position of his skull bones
• Observing his face and neck for any outward signs of abnormalities
• Listening to his heartbeat
• Feeling his pulse
• Listening to his breathing
• Feeling inside his mouth with a finger to see if he has a cleft palate
• Checking his fingers and palms
• Gently feeling his abdomen to check the size of his liver, kidneys and spleen
• Feeling along his spine for any defects
• Checking his feet and ankles
• Examining a boy’s testicles to make sure they have both descended
• Examining a girl’s labia to check that they are not joined together
• The last test to be done is to check the baby’s hips. This is done by gently bending his knees up to his chest and by rotating his legs slightly. Babies tend to cry when this is done, which is why most doctors leave it until last! Sometimes the doctor will pick up a slight clicking sound, which shows that the ball of bone at the top of the leg is not seated properly into the socket joint. If left unattended this could cause a limp when the baby begins to walk. The treatment for this is usually very simple; a body splint can be worn for a few weeks. Very rarely, an operation may be needed.

Reflexes

Babies are born with several automatic reflexes, which are tested to make sure that the nervous system is working properly. The doctor will check that the baby:

• Sucks on a finger that is put in his mouth (the sucking reflex)
• Turns his head and opens his mouth ready to feed when his cheek is stroked (the rooting reflex)
• Tightly grasps a finger that is put into his hand (the grasping reflex)
• Shoots out his arms and legs if something startles him (the startle or ‘Moro’ reflex)
• Makes walking movements with his legs when he is held under his arms in an upright position with his feet on a firm surface (the stepping reflex)

Newborn blood spot screening

This is a blood test that is done routinely towards the end of your baby’s first week. Your midwife will take some drops of blood from the baby’s heel by pricking it, which will be tested for rare but serious conditions. All babies are screened for:

• Phenylketonuria (PKU) – About 1 in 10,000 babies born in the UK has PKU. Babies with this inherited condition are unable to process a substance in their food called phenylalanine. If untreated, they can develop serious mental disability.
• Congenital hypothyroidism (CHT)- About 1 in 4,000 babies born in the UK has this condition. Babies with CHT do not have enough of the hormone thyroxine. Without this hormone, they do not grow properly and can develop serious physical and mental disability.
• Sickle cell disorders – About 1 in 2,500 babies born in the UK has a sickle cell disorder. These are inherited conditions that can affect the red blood cells. If a baby has a sickle cell disorder, their red blood cells can change shape and become stuck in the small blood vessels. This can cause pain and damage to the baby’s body, infection, or even death.

In some areas screening is also offered for cystic fibrosis and MCADD. Please ask your midwife which conditions are screened for in your area.

• Cystic fibrosis – About 1 in 2,500 babies are born in the UK with this inherited condition. It can affect the baby’s digestion and lungs, babies with this condition may not gain weight well, and have frequent chest infections.
• Medium Chain Acyl-CoA Dehydrogenase Deficiency (MCADD) – About 1 in 10,000 babies born in the UK has MVADD. Babies with this condition have problems breaking down fats to make energy for the body. This can lead to serious illness, or even death.

Hearing Test

Some health authorities are now offering this new check at birth – if yours doesn’t you will receive an appointment from your health clinic within a few weeks. The test is completely harmless. The midwife will place a soft-tipped ear piece in the outer part of the baby’s ear and this quietly plays a clicking sound. If your baby can hear okay, a series of lights will flash on a little electronic box, signifying that the ear is responding normally to sound. The test takes a few minutes and can be done on a sleeping baby. If you get a “false” reading, don’t
worry it is not 100% accurate, especially on a tiny baby.

Vitamin K

This isn’t a test as such, more a preventative measure. Shortly after your baby is born, you’ll be offered a dose of Vitamin K, by injection for your baby. Newborns arrive in the world with very little of this essential vitamin which helps their blood to clot.

This is given to prevent babies from developing a (rare, but serious and potentially fatal) bleeding disorder, called haemorrhagic disease of the newborn (HDN) or Vitamin K Deficiency Bleeding (VKDB). It can be given either as an injection or by mouth.

Giving babies vitamin K isn’t an entirely straightforward issue. Some parents are concerned about their babies being given it by injection because in the early 1990s a piece of research was published, which showed an association between babies being given Vitamin K by injection, and an increased incidence of childhood leukaemia. It didn’t show that the injection actually caused the leukaemia, though. This led to a change in policy in a lot of hospitals at the time, to giving babies Vitamin K orally instead (which in the study showed no connection with leukaemia). Since this first (small) study was published, there have been several larger-scale studies published which have not shown any connection between the Vitamin K injection and leukaemia. So the current weight of the research evidence is against
there being any link, although because of the first study, it can’t be said that all the research excludes the possibility. But because of the weight of evidence against the link, most  hospitals have now reverted to offering the injection, although parents can, of course, request that the Vitamin K is given orally – or refuse it altogether. If it’s given orally, it needs to be given in a series of doses in order to be effective (babies aren’t properly protected unless and until all the doses are given). Because of this, some experts take the view that the injection gives better protection. When it comes to your baby, though, the choice is yours.

Because the risk of the baby developing HDN is small, about 1 in 10,000 (without Vitamin K being given), some parents question whether it’s really necessary for Vitamin K to be given to all babies. The reason it’s offered to all is that it’s difficult to identify which particular babies are most at risk of developing the disease. However, babies are thought be at a higher risk of this happening if they’re premature (born before 37 weeks), were born by forceps, ventouse or caesarean, have liver disease, or their mums are taking anticonvulsants, anticoagulants, or medication to treat TB.

If, after he’s born, your baby has any bleeding from his nose or mouth, or any unexplained bruising, do let your midwife, health visitor or GP know about this. Also, if your baby has jaundice after about two weeks, you should tell your medical carers about this too, as it may indicate liver problems which put him at increased risk of HDN.