Newborn screening tests in India every baby should have before going home

Before going home, every newborn in India should ideally have a hearing test, a pulse oximetry check for heart disease, a heel prick blood test (at least for thyroid), a red reflex eye check and a full examination including the hips. These tests find hidden problems that do much better when treated early. Not every hospital offers all of them, so ask.

What screening tests should a newborn have in India?

The core tests Dr Dutta advises for every baby are:

• A hearing screen
• Pulse oximetry, a painless oxygen check for serious heart defects
• A heel prick blood test, at least for congenital hypothyroidism
• A red reflex eye check
• A full head-to-toe examination, including the hips
• A bilirubin check for jaundice

WHO recommends universal newborn screening for hearing and for eye problems, and a skin bilirubin check at discharge.¹ Each test looks for a condition that is invisible in the first days but changes a child's life if missed. Most babies pass every test. The tests exist for the few who look healthy but are not.

Why do newborns need a hearing test?

Because hearing loss is common, invisible at birth, and treatable. Without a test, it is often found late, when the child is not talking.

In a ten-year Indian hospital programme, about 5 in every 1000 screened babies had hearing loss.² The rate was much higher in babies with risk factors, such as a stay in the NICU.² The brain learns language from sound in the early months. Finding hearing loss early means hearing aids and therapy can start while the brain is most ready to learn.

How is a newborn hearing test done?

It is quick, painless and usually done while the baby sleeps. WHO recommends either an otoacoustic emission (OAE) test or an automated auditory brainstem response (AABR) test.¹

• OAE: a soft probe in the ear canal plays clicks and listens for an echo from the inner ear.
• AABR: small sticky pads on the head pick up the brain's response to sound. It also tests the hearing nerve.

Many units prefer AABR for babies who were in the NICU, because it checks the hearing nerve as well as the ear. Each test takes a few minutes.

What does "refer" mean on a newborn hearing test?

"Refer" means the baby did not pass this time and needs a repeat test. It does not mean your baby is deaf.

Fluid or vernix in the ear canal in the first days is a common reason. In an Indian study, the OAE test gave more false alarms than a later, more detailed test.³ Most babies pass on the repeat. But please do go back. If the second screen is also not passed, the next step is a full diagnostic test called BERA (brainstem evoked response audiometry), done by an audiologist.³

When should my baby's hearing test be done?

Every baby should have a hearing screen no later than 1 month of age.⁴ A baby who does not pass should have a full hearing test, ideally by 3 months.⁴

Most hospitals do the screen before discharge. If yours did not, arrange it at your first paediatric visit. If hearing loss is confirmed, help should start as soon as possible. The earlier a child gets hearing aids and therapy, the better speech and language usually develop.

Which babies need hearing checks even after passing?

Some babies need follow-up hearing tests even if they pass at birth. In Indian studies, hearing loss was more common in babies with a NICU stay, severe birth asphyxia (lack of oxygen at birth), very low birth weight or high jaundice.^2,3

Other reasons for follow-up include a family history of childhood hearing loss, meningitis, and certain infections in pregnancy. At any age, see a doctor if your baby does not startle to loud sounds, does not turn to voices by about 6 months, or is not babbling.

What is the pulse oximetry test for newborns?

Pulse oximetry is a painless check of the oxygen level in the blood, using a light sensor on the skin. It helps find critical congenital heart disease, which means heart defects that need surgery or a procedure in the first weeks.

Some of these babies look completely normal for a day or two. A Cochrane review found the test picks up about 5 of every 6 babies with these defects, with very few false alarms.⁵ False alarms were fewer when the test was done after 24 hours of age.⁵ It does not catch every heart defect, so it adds to the doctor's examination rather than replacing it.

What counts as a pass or fail on pulse oximetry?

The sensor is placed on the right hand and on one foot. Under the updated American approach, a baby passes with an oxygen reading of 95 percent or more in both the hand and the foot.⁶

Borderline results need only one repeat test before a decision is made.⁶ A baby who fails needs a careful examination and an echocardiogram (heart ultrasound) before going home. A failed screen can also point to other problems, such as lung disease or infection.

What is the heel prick test?

The heel prick test uses a few drops of blood from your baby's heel to look for hidden hormone, blood and metabolic conditions. The blood is put on a filter paper card or in a tube.

The Indian Society for Pediatric and Adolescent Endocrinology advises screening ideally at 48 to 72 hours of age.⁷ Premature and low birth weight babies should also be screened at 48 to 72 hours, and sick babies at least by 7 days.⁷ The prick stings for a moment. Breastfeeding or skin-to-skin during the test helps your baby settle.

Why is the newborn thyroid test so important?

Congenital hypothyroidism means the baby's thyroid gland does not make enough hormone, and the brain needs that hormone to develop. Babies look normal at birth. Untreated, it leads to permanent intellectual disability.

It is more common in India than many people think. A national ICMR study screened over 100,000 babies and found it in about 1 in 1130 after excluding temporary cases.⁸ The treatment is simple: a daily tablet of thyroid hormone. Started early, children grow and learn normally. In Dr Dutta's opinion, no Indian baby should go home without this test being planned.

Can the thyroid test be done on cord blood?

Yes. Indian guidelines accept either cord blood or a postnatal heel prick sample for thyroid screening.⁷

Cord blood is handy when mother and baby go home within a day. The heel prick at 48 to 72 hours is the ideal time.⁷ If the screening TSH (thyroid stimulating hormone) is raised, the baby is called back for a confirmatory blood test.⁷ Please keep your phone switched on in the days after discharge and give the hospital a number that will be answered.

Does my baby need a G6PD test?

Dr Dutta advises it, especially in families with a history of G6PD deficiency or severe newborn jaundice. G6PD deficiency is an inherited enzyme problem that makes red blood cells fragile.

It is common in South Asia, with estimates of about 4 to 15 percent in different regions.⁹ In an Eastern Indian screening study, about 3 percent of newborns had it, more often boys.¹⁰ Affected babies can develop sudden severe jaundice.⁹ Later in life, certain medicines, fava beans (bakla) and infections can trigger a crisis. Knowing early lets us watch jaundice closely and gives you a list of things to avoid.

What other conditions does the heel prick find?

Expanded panels can test for congenital adrenal hyperplasia (CAH), galactosaemia, biotinidase deficiency and others. Each is rare, but together they add up.

In the ICMR study, CAH, which can cause a life-threatening salt-losing crisis in the first weeks, was found in about 1 in 5762 babies.⁸ In the Eastern Indian study, partial biotinidase deficiency was the most common finding.¹⁰ Panels differ between hospitals and states, so ask exactly what your baby's test covers and how you will get the results.

What does a positive screening result mean?

A positive screen is not a diagnosis. It means your baby needs a confirmatory test, quickly.

Most babies who screen positive turn out to be fine on the second test. But a few have the condition, and for them every day counts. If the hospital calls you, go for the repeat test as soon as you can. Do not wait for your routine visit.

What is the red reflex test?

The red reflex test checks that light shines evenly through both eyes. The doctor looks through an ophthalmoscope for the orange-red glow from the back of each eye, the same red-eye you see in flash photos.

The American Academy of Pediatrics calls red reflex testing an essential part of the newborn and infant examination.¹¹ A dull, white or uneven reflex can point to a cataract, glaucoma or, rarely, a cancer of the eye called retinoblastoma. You can help too. If you ever see a white pupil in a photo, or one eye reflecting differently, show it to a doctor.

Why do doctors check my baby's hips?

To look for developmental dysplasia of the hip, where the hip joint is loose or not formed properly. It causes no pain or obvious signs in the first year, but it is easier to treat when found early.¹²

The doctor gently moves each leg to feel whether the hip is stable. Your doctor may suggest a hip ultrasound if there are risk factors, such as a breech position in late pregnancy or a family history. Many mild cases settle by themselves.¹² Let your baby's legs bend up and apart freely. Do not wrap them straight and tight.

Will my baby's jaundice be checked before going home?

Yes, it should be. WHO recommends checking all babies with a skin bilirubin meter at discharge.¹

A high skin reading is confirmed with a blood test. If you leave hospital early, ask when and where the next jaundice check should be done. Yellow colour in the first 24 hours, or yellow palms and soles at any time, needs a doctor the same day.¹

What should I ask before leaving the hospital?

These questions take two minutes and can prevent a missed diagnosis:

• Has my baby had a hearing screen, and what was the result?
• Has pulse oximetry been done after 24 hours?
• When will the heel prick be done, what does it test, and how will I get the results?
• Has the red reflex been checked in both eyes?
• Have the hips been examined?
• Does my baby need any follow-up tests, and when?

If anything was missed because you went home early, it is not too late. Arrange it at the first paediatric visit, usually within the first week.

When should I see a doctor after newborn screening?

See your paediatrician promptly if:

• The hospital calls you about any abnormal screening result
• Your baby did not pass the hearing screen and no repeat has been booked
• Your baby looks blue around the lips, breathes fast, or tires during feeds
• You notice a white pupil or one eye that looks different
• Your baby is very sleepy, constipated, has a large tongue or a hoarse cry, or stays yellow beyond 2 weeks

Screening is a safety net. It works only if every result is followed up.