Table 4 Illustrative quotations for Theme 2 – practicalities of the neurological examination in unwell term neonates

Attitudes towards different aspects of the neonatal neurological examination

 The achievable or important

  Assessing the level of consciousness

Why assessing conscious level is important for us immediately after birth is making this decision: does the baby have an encephalopathy, and should they be cooled or not…. it can be quite subjective

3, C, Neo, M

I think it’s fairly simple, isn’t it? It… it almost feels to me like common sense. You know?…How difficult can it be to differentiate between somebody who is completely normal, to somebody who is completely unconscious, and somebody who is sat in the middle?

6, C, Neo, M

I think it’s really hard to assess conscious levels in babies other than, “are they awake? Are they asleep?” Um, I think definitely it would be good… like, in adults and in children, if you have this scale that you can, use as a tool to assess and to quantify, in a way

18, Tr, Paed, F

I would never think of using a Glasgow Coma Score. I’ve never seen GCS written in a baby’s notes, term or preterm, and I’ve never heard anyone in the notes or over the phone discuss the GCS of the baby when describing their neurological status. No. It’s not something I would ever use

4, Tr, Neo, M

I would probably use it, but use the modified, um, GCS but not, er… maybe subconsciously rather than absolutely consciously

15, Tr, PNeurol, F

I think AVPU is nice that it’s, um… you know, it’s fairly obvious if a patient responds to pain, right? And it’s fairly obvious if they respond to voice, and it’s fairly obvious if they are awake. But because it’s fairly obvious, it means that it’s not that sensitive to subtle changes in the patient’s status

11, C, Paed, M

I’ll tell you one of the things that has recently come up is… there is a dropped-baby guideline that is being set up nationally… and as part of that they would like us to use a modified Glasgow Coma Scale. Neonatologists think that Glasgow Coma Scales are meant for Paediatricians or adults or whatever be the case and it’s not for neonates… But you’ve now just popped this in front of me and say, “actually look at it and tell me: can you do this?” I’m thinking “Of course I can!”

6, C, Neo, M

  Muscle tone and power

Tone is easy

5, C, Neo, M

[Distinguishing tone from power] I think trainees get it confused all the time

3, C, Neo, M

I think their first assessment of power would be “are they making antigravity movements?” as a baseline….People want to do their formal assessments of power, which in a neonate you can’t do

2, Tr, PNeurol, M

The power is to say when they, um, when they kick their legs, kind of, against you, or you’re holding their arms and they’re trying to free themselves from you

18, Tr, Paed, F

Muscle power again depends on the state of the child

23, C, PNeurol, F

  Anterior fontanelle

Assessment of the anterior fontanelle is a relatively straightforward thing to do because we all do it very frequently

9, C, Neo, F

I don’t know what I’m doing with it. I mean, like… people like to tell me that they can work out whether the baby is dehydrated but… you’ve got to be profoundly dehydrated before your anterior fontanelle goes in. I mean, I suppose I do… I do feel it

7, C, Neo, M

So, they may be wearing a head-gear for the tube where you can’t assess the fontanelle or even the head circumference

12, C, PNeurol, M

  Movements and posture

Presence of abnormal movements is again an observation—very heavily dependent on experience

9, C, Neo, F

Quality of spontaneous movements is an important thing to look at. It is easy to look at. It helps a lot

6, C, Neo, M

It is fairly customary for us to start with looking at the posture of the baby, which itself is a marker of neurological status

9, C, Neo, F

 The impossible or unimportant

  Truncal tone

Truncal tone would be difficult to assess if they are lying down and I can’t lift them up

21, Tr, Paed, F

  Primitive reflexes

Primitive reflexes may not be possible if they’re fragile and on a ventilator. You’re not going to be able to pick them up or do a Moro

12, C, PNeurol, M

Nearly everyone who’s done more than a week on neonatal, of neonatal attachment, should know how to do and interpret a Moro

9, C, Neo, F

What is the value of a Moro reflex? I think there is a little bit of a lack of knowledge

6, C, Neo, M

  Cry

I suppose, assessing what the difference between a ‘cry to pain’ and a ‘moan to pain’, and so an irritable… what’s the difference between an ‘irritable cry’, a ‘cry to pain’’, and a moan to pain’? People might struggle with that

2, Tr, PNeurol, M

I think a normal cry is easy to differentiate between an irritable cry. And moaning is easy. So cry and moaning, you can differentiate between these two. And an irritable cry you can tell. I think you can differentiate these two

6, C, Neo, M

  Sensory levels

Even trying to determine a sensory level, you can. Not always the most reliable, but in some situations it’s very obvious what the sensory level is when you examine the baby

1, SG, PNeurol, F

  Tendon reflexes

I think tendon reflexes are doable, it just takes a bit of practice and you’ve got to be consistently doing them fairly semi-regularly to continue with that

11, C, Paed, M

I have to say, um er, definitely deep-tendon reflexes is not something that I am, er, confident at doing in a neonate

18, Tr, Paed, F

Well I think because we don’t use tendon hammers in neonatal unit. I use stethoscopes, which is a bad way

5, C, Neo, M

  Cranial nerves

Cranial nerve examinations: oh my God! No, I don’t think I’ve ever done that in a baby

7, C, Neo, M

Sucking: yes; pupil response: absolutely; gag reflex: we don’t do much, but yes, if this could be done; …. facial expression: yes;.… eye movements, including nystagmus, ophthalmoplegia: yes; visual ability, fixing-and-following in neonate … becomes difficult—I don’t find it very easy; …. pupillary reflexes: yes

16, C, Paed, M

Standardised neonatal neurological examinations

 Positive views

Our unit is quite good because most of … we have quite good AHP cover and all our AHP’s are trained in various neurological assessment err including the Hammersmith. So, babies who are on HDU / SCBU invariably will get weekly Hammersmith and that’s chartered in the notes and we are able to see it

20, C, Neo, F

I love the stick diagrams. I think they are fantastic. Um, and I love the way that they, um, they tell you how to do it

10, C, Neo, M

If I was a paediatrician at a DGH who hadn’t done a lot of neonates, and I was faced with a newborn baby, it might be quite useful structure for me. It would give me something… it would remind me, kind of, what to do

7, C, Neo, M

 Negative views

I’ve never seen, you know, the Hammersmith model printed out and put in the notes with tick boxes

4, Tr, Neo, M

If they’re really sick and they’re tubed there are certain things you are not going to be able to do

19, Tr, Paed, F

When I was a very junior doctor, we used to go and do, sort of, assessments of gestational age, erm, using those standardised scores. I can’t remember what the name of the forms were, we haven’t used it for so many years now

3, C, Neo, M

It’s a very long examination and this is something that almost borders into ‘do you really need to do it?’. Because it is quite disturbing to the preterm infant, or even to the term infant

9, C, Neo, F

It’s got to be simpler. I think the more complicated things perhaps would help research more, but it probably wouldn’t help practical day to day basis at all

23, C, PNeurol, F

The challenge is people need to be trained to do it properly

9, C, Neo, F

The writing is quite small for somebody with my eyesight

7, C, Neo, M

It’s busy. It’s got a lot of stuff in it. I think people need to think about, if they are trying to revamp this, to try and make it something that is useful that is one page and not one, two, three, four, five

6, C, Neo, M