1. Hannah Shore Consultant Neonatologist Leeds
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. newbornphysical.screening.nhs.uk/
Screening Summary:
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newbornphysical.screening.nhs.uk/

10. newbornphysical.screening.nhs.uk/
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newbornphysical.screening.nhs.uk/

11. Head
What should you look for?

12. Head Circumference Fontanelles 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
Truncus arteriosus

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
Ductus arteriosus
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
60-80% positive exam and >90% USS abnormalities resolve themselves

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 Surgical reduction of the femoral head
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

51. What to do? Bilateral absence Unilateral absence
URGENT referral – needs endocrine investigation
Unilateral absence
Review at 6 months
Refer if still absent
Surgery by 13 months
If girl and inguinal hernia -always think – is this an ovary or ??testicle?

52. Cleft palate
Can be hard to diagnose

53. Neurology / development
Fix and follow
Head held in line in ventral suspension
Symmetrical moro
Smiles

54. Summary Review of 6 week check Key areas Introduced concept of NIPE
Eyes
Heart
Hips
Testis
Cleft palate
Introduced concept of NIPE