infection.
Conversely, polyhydramnios will alert the examiner to consider the following:
Duodenal atresia or stenosis (Rajiah 2009)
Oesophageal atresia.
Exposure to the effects of intrauterine teratogens has been investigated and publicised over recent decades, but arguably the most common causes of such exposure is smoking and excessive alcohol consumption during pregnancy.
Smoking in pregnancy
Smoking is the most common substance dependency, yet the most preventable. Reduction in maternal smoking during pregnancy remains high on the public health agenda through smoking cessation initiatives as part of maternity care (NHSE 2016; NHS 2017; NICE 2018c). Clinical guidance can be found on the NICE website at http://www.nice.org.uk/nicemedia/live/13023/49346/49346.pdf. There is compelling evidence highlighting the adverse effects of maternal smoking in both the antenatal and postnatal periods (La Souef 2000; Gilliland et al. 2001; Landau 2001; Stocks and Dezateux 2003; British Medical Association 2004; Bradley et al. 2005). The adverse health implications for the newborn and older children are numerous and can impact upon mortality and morbidity.
Perhaps the most significant, devastating and publicised adverse effect of parental smoking is the increased risk of SIDS (McMartin et al. 2002; Anderson et al. 2005; Matturi et al. 2006; Sellwood and Huertas‐Ceballos 2008). The hypothesis surrounding this causal relationship is multifactorial, ranging from respiratory infection susceptibility to altered respiratory control mechanisms (Hofhuis et al. 2003). This positive association cannot be underestimated nor ignored; therefore, the prevention of SIDS is high on the maternity services' health education agenda for the newborn examination. There should be reinforcement of the potential harmful long‐term effects of smoking in the postnatal period upon the newborn and into childhood as part of the newborn NIPE health education.
Maternal alcohol consumption
Fetal alcohol exposure from excessive maternal consumption is associated with dysmorphic features and varied neurodevelopmental and behavioural disorders ranging from fetal alcohol syndrome to fetal alcohol spectrum disorders (Disney et al. 2008). Maternal alcohol consumption is often associated with an existing suboptimal social environment (Dawson 2003). The likelihood of domestic abuse may also be greater. The newborn can also suffer withdrawal symptoms from prenatal alcohol exposure that may result in seizure activity (Lall 2008).
Admittance to alcohol consumption during pregnancy in excessive amounts is often retrospective (Jacobson et al. 2002); therefore, intervention and preventative strategies must be put in place for subsequent pregnancies. Disney et al. (2008) reports on the long‐standing evidence (Olson et al. 1997; Roebuck et al. 1999) to support altered neurobehavioural abilities in infancy through to antisocial behaviour and attention deficit disorders in children from small amounts of alcohol during pregnancy (Jacobson et al. 2002; Sayal 2007; Sayal et al. 2009). Enquiries into maternal alcohol and units consumed are made by the midwife at the prenatal booking interview. The current social acceptability of alcohol consumption in the United Kingdom may be harbouring an upsurge in a future generation who are affected by prenatal alcohol exposure. Some women, particularly the teenage population, may be engaging in alcohol misuse around the time of conception and beyond until confirmation of the pregnancy. For some newborns, the cessation of alcohol use, even early in the first trimester, may be too late.
Maternal substance use
Maternal substance use signals a probable newborn withdrawal process and a challenge to the health care team in establishing the exact nature of the drugs taken. In the first instance, the NIPE practitioner must establish what illicit drugs have been taken in pregnancy and the immediate pre‐labour period. However, obtaining an accurate substance use history is often fraught with imprecise maternal disclosures. Such behaviour can be linked to the social stigmatisation of drug use and the fear of the newborn being placed in care. Sensitive, but direct, further maternal questioning may be required, especially in cases of polysubstance use.
The withdrawal timelines for the common illicit substances have been well documented over recent years. Withdrawal from opiates and heroin can be evident in the newborn within hours of birth, whilst cocaine and amphetamine withdrawal begins within 48 hours of birth (Wang 2010) and withdrawal from methadone does not occur until 48–72 hours of age (Leggate 2008), but it can be as long as 7–14 days before withdrawal is evident (Lall 2008; Wang 2010). The longer half‐life of methadone is known to prolong and increase the severity of the withdrawal symptoms. Neonatal abstinence syndrome (NAS) is often considered the foremost adverse condition for the newborn of the substance misuse mother; however, the effects upon fetal brain development have far more significant and long‐lasting consequences. Substance use in the first 20 weeks of pregnancy can cause disruption in the cytogenesis and cell migration processes. In the subsequent weeks of pregnancy, cell differentiation and overall brain growth can be disturbed (Wang 2010), including midline defects and congenital heart defects (Mone et al. 2004).
Neonatal abstinence syndrome
NAS indicates multisystem involvement, resulting in a cascade of symptoms. Fetal growth is disrupted, resulting in growth restriction that can independently place the newborn at greater risk of co‐morbidity (Smith et al. 2006). Normal neurobehavioural function is altered, resulting in a display of central nervous system instability, abnormal feeding behaviour, respiratory compromise and gastrointestinal symptoms (Volpi‐wise 2005; Hamden 2009). Seizure activity can manifest as a late onset symptom of diazepine withdrawal.
NAS can occur with prescribed maternal medication. Morphine‐based analgesia for long‐term protracted pain management and psychotropic drugs for mental illness are the most common. The social context of the mother requiring morphine for long‐term pain in many cases differs from that of the illicit substance user. Nonetheless, a sensitive approach is required with these parents when reiterating information about the clinical presentation of NAS, as they will have already received information in the prenatal period.
Where maternal substance use is known, it may be prudent for midwives and neonatal nurses to refer the examination to a senior paediatrician because the newborn will require a more thorough examination to assess for withdrawal symptoms.
Risk factors and the newborn examination
Intergenerational traits may indicate an inheritance risk to the newborn. History taking may elicit such conditions (see Chapter 8). However, they may have already been identified in the prenatal period, particularly the haemoglobinopathies, e.g. thalassaemia or sickle cell disease. The NHS national Antenatal Screening Programme performs well in such cases. The NIPE programme provides seven national risk factors that must be applied to by the NIPE practitioner when performing the newborn examination (PHE 2018a, 2020c). Table 1.4 outlines the four screening components from the NIPE Programme Handbook (PHE 2020c) and conditions that carry a predictive risk, as well as other conditions that may have a positive family trait.
It can be argued that some elements of the newborn screening agenda perform poorly in terms of predictive risk based on clinical examination alone. The newborn examination does have its limitations. The most common example is current screening techniques for congenital heart defects (CHDs) (see also Chapter 2). It is estimated that over half of CHDs are not detected in the newborn period (Wren et al. 2007; Sharland 2010). Despite prenatal cardiac screening as part of the fetal anomaly scan and the clinical cardiovascular assessment at the newborn examination, current methods of detection do not compete on merit as an effective screening tool. This is particularly the case for critical duct‐dependent anomalies (Abu‐Harb et al. 1994; Green and Oddie