The 6 week check

1. The 6 week check Hannah Shore Consultant Neonatologist Leeds

2. Plan • Point of the newborn check • Eyes • Heart • Hips • Testis • Cleft palates

3. Why do it?

4. Why do it? • Identify a range of conditions so that further assessment can be made and specialist care initiated ASAP • Not fool proof • ? Tie up results / safety net for hospital follow up

5. What info do you need?

6. What info do you need? • Badger letter from hospital • What do you want on this? • Initial check results • On Badger • Child health record • FH / Pregnancy details / antenatal screening • General health / development of baby –weight etc • Parental concerns • Consent • ??NIPE

7. What is NIPE? • Currently hospital IT for newborn check • Screening parameters set locally • Output around 4 key KPIs • Input follow up screening data • Accessible from community in due course

8. newbornphysical.screening.nhs.uk/

9. Screening Summary: newbornphysical.screening.nhs.uk/

10. newbornphysical.screening.nhs.uk/

11. Head • What should you look for?

12. Head • Circumference • Following centiles? • Several measurements • If concerned – can do USS • Fontanelles • Too wide – skeletal dysplasia • Too small – craniosynostosis • Posterior is small • Anterior up to 4cm is ok • Think sutures

13. Eyes • What are you assessing?

14. Eyes • Structural issues • Red reflex – 30 cm away, large light • Fix and follow • Conjugate movements

15. Risk factors • <32 weeks <1500g • FH • Maternal infection • HSV

16. Eyes • What pathology may you find?

17. Eyes • Cataract • Retinoblastoma • Coloboma

18. Cataracts • 2:10,000 - 1/5 family history • Absence of red reflex / cloudy lens • Congenital infection – toxo / rubella / HSV • Metabolic disorder - galactosemia

19. Retinoblastoma • Leukocoria – absent red reflex • 1:20,000

20. Coloboma

21. Any abnormality • Refer URGENTLY to ophthalmology • Each 3 week delay leads to drop in snellen acuity by one line

22. Heart • Serious congenital heart disease 6-8/1,000 • Antenatal diagnosis in approx 25-30% • 30% critical CHD diagnosed after discharge • Often normal at 24 hour check

23. Saturation screening • 75% sensitivity – true positives • 99% specificity – true negatives • May be normal initially if duct dependent or leftoutflow tract involved • Hypoplastic left heart syndrome • Pulmonary atresia • Tetralogy of Fallot • Total anomalous pulmonary venous return • Transposition of the great arteries • Tricuspid atresia • Truncusarteriosus

24. Questions to ask parents?

25. Questions to ask parents? • Breathless on feeding • Slower to feed • Colour change • Increased resp rate

26. Cause of concern • Tachypnoea • Apnoea and colour change • Resp distress • Cyanosis • Visible pulsations • Murmurs • Absent/ weak femorals • REFER at time of examination

27. Examination • Observation • Palpation – pulses, heaves, thrills • Cap refill time • ? Saturation monitoring

28. Examination

29. Location of murmur • Aortic – high pitch -diaphragm • Aortic stenosis • Pulmonary - ? Radiate to back • Ductusarteriosus • Pulmonary stenosis • ASD • Coarctation • Mitral- low pitch rumble - bell • VSD • Apex • Mitral regurgitation • Very difficult to be specific

30. VSD • Classically presents at 6 week check • Drop in PVR – shunt occurs • Often presents in failure • Other pathology

31. Coarctation of aorta

32. Hypoplastic left heart

33. Hips • Developmental Dysplasia of the hips • Progressive condition • Easy to miss • Needs regular checks

34. Size of the problem • DDH affects around 2000 infants per year • Incidence varies according to criteria • Approx 1:1000 actually dislocated • Approx 1:100 degree of instability • Around 4% of our babies get USS

35. What is it? • Developmental growth disorder • Needs early detection • 29% of hip replacments in the under 60s • National clinical screening from late 1960 • USS from mid 1980s • Xray – no use as joint cartilaginous

36. What are the risk factors?

37. Risk factors • Breech – >36 weeks • 23% of all DDH • Family history of DDH needing treatment • Multiple with 1 twin being breech • Large girl – hormones! • Oligohydramnios • Associated talipes / positional problems • Majority have NO risk factors

38. USS –when? • USS gold standard test for hip dysplasia • Normal clinical exam – within 6 weeks • Expert opinion - within 8 weeks • Abnormal clinical exam – within 2 weeks • Expert opinion - within 3 weeks

39. USS them all?? • Some centres do • Cost – £43 • High False positive rate • Low late presentations • Additional cases treated – many would resolve • Cochrane review – no change in treatment / late diagnosis

40. Alpha angle Acetabular roof Ileum

41. Dysplastic

42. Dislocated

43. Types of problems • Dysplastic • Low dislocation • High dislocation

44. Examination • Full range of hip movement? • Symmetrical knees when flexed • Leg creases • OrtoLani – disLocated • Try and relocate • Barlow – dislocataBle • Try and dislocate

45. Discussion with parents • Any difference in skin creases in thighs • Limited movement • Leg length discrepancy • Click • Walk with limp or waddle

46. If test abnormal • Refer directly for urgent expert opinion • USS to be done • To be seen by 10 weeks of age

47. Treatment • Pavlik harness • Rash, femoral nerve palsy, pressure sores • Surgical reduction of the femoral head • Needs long term follow up regarding actual outcomes

48. Practical bit….

49. Testis • Cryptorchidism affects 2-6% boys at birth • Risk factors • Pre term / low birth weight • First degree relative • Complications • Increased risk of malignancy • Reduced fertility

50. Examination • Scrotum -size /symmetry • Penis – position of urethral opening • Location of testis – may be in inguinal canal