The 6 - 8 week check Dr Chris Cooper - PowerPoint Presentation

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The 6 - 8 week check

Dr Chris Cooper( Paediatrician, Stockport )

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NICE GUIDANCE NG194 ( April 2021 )

UK National Screening Committee 2008

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Documentation

Record in `red book` and maternal health record

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Lots of resources and NIPE e-learning for health module ( need to register )

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Infant Examination

No national NIPE standards for 6-8 week checkRecord on `GP IT system` and `red book`Local commissioners are responsible

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6 – 8 week check

Examination same as newborn check

AND

Check social smile

Check visual awareness ( 12” away thro` 45 arc from midline)

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Opportunity to assess mum and baby general health and promote well being

….Postnatal care up to 8 weeks after birth : detailed guidance for mum and baby ( NG194 )

eg

Baby

: breast feeding, ( www.babyfriendly.org.uk

initiative ) cot death advice, parenting, promote bondingMother : contraception, postnatal depression, support

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Normal values

Resps 30 – 60Heart Rate 100 – 160

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Examination

Poor evidence base !

Review health of mother and baby

Baby : feeding, bowel action , urine stream

Weight ( breast fed charts now available)Length ?! ( need 2 people )OFC measure and plot

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Newborn Examination

Appearance ( behaviour, colour, breathing, activity, posture )Head ( palate, OFC,

eyes

red reflex, squint ), Neck

Limbs, hands, symmetry Heart ( murmurs, femorals ), LungsAbdomen, Genitalia (

testes), anusSpine, SkinCNS ( tone, reflexes only if concerned )Hips ( symmetry, Ortolani, Barlow )( national screening group )

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Poor weight gain ?

NICE guidance on `faltering growth`NG 75( eating behaviours, healthy diet, when to investigate and refer )

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Congenital dermal melanocytosis

Blue Grey Patches( formerly known as Mongolian Blue Spots )Good PIL on British Association Dermatology

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Missed diagnosis can result in avoidable harm and litigation !

Eyes , heart, testes, hipsEg avoidable hip surgery, missed retinoblastoma, pulmonary hypertension from cardiac defect, infertility, increase testicular cancer risk…..

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Absent red reflex

“About 2 or 3 in 10,000 babies have problems with their eyes that require treatment” ( NIPE )

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EYES : absent red reflex

`leukocoria` could be a result of problem with……Cornea, lens, vitreous, retina

Eg Cataract, Retinoblastoma

Refer opthalmology urgently…….

( Stockport : Miss Anna Maino )

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Babies with

- neurological/neurodevelopmental conditions or - sensorineural hearing impairment - babies with chromosomal abnormalities, such as Trisomy 21, will require regular monitoring, even if the examination shows no evidence of an ocular problem. ( NIPE )

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Hips

“About 1 or 2 in 1,000 babies have hip problems that require treatment” ( NIPE )

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Hip screening examination

Ortolani BarlowIs the hip dislocated or dislocatable ?( show on hip model )Distinguish `clunks` and `clicks`

( ? Ligamentous )

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Risk factors for DDH

First-degree family history.( national )breech presentation at or after 36 completed weeks of pregnancy, irrespective of presentation at delivery or mode of delivery ( national )breech presentation at delivery if this is earlier than 36 weeks ( national ).congenital talipes, metatarsus adductus, torticollis, oligohydramnios ( RMCH )

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Developmental dysplasia

( ie may have been normal at birth )

Risk factors or clinical findings ….?

Refer to hip screening clinic

( Stockport is `one stop` for scan, opinion, treatment, arrange follow up )

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Murmurs

“Around 1/200 babies have a heart problem that needs treatment” ( NIPE )

“around 30- 50% babies may have a heart murmur “

( received wisdom / experience ! )

Symptoms and signs…..also important, not just about murmurs…..

Signs of heart failure in newborn…. ?

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Duct dependent lesions

Should present within 28 daysEg hypoplastic left heart

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Risk factors for CHD

•family history of CHD (first-degree relative)•fetal trisomy 21 or other trisomy diagnosed (these babies have high risk of cardiac defects and require continued surveillance)•cardiac abnormality suspected from the antenatal scan•maternal exposure to viruses, for example, rubella during early pregnancy

•maternal conditions, such as diabetes (type 1), epilepsy, systemic lupus erythematosis (SLE)

•teratogenic drugs taken during pregnancy

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Symptoms and signs of cardiac disease

Symptoms : FTT, poor feeding, sweating, tachypnoea, pallor, apnoea

Signs : tachypnoea at rest, chest recession, tachycardia, absent femoral pulses, poor perfusion, cyanosis, murmurs,

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Significant murmurs

Loud, Harsh quality, heard over wide area Associated symptoms and signsBenign murmursShort, soft, systolic

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Can you do O2 saturations in primary care ?

( should have been picked up at newborn check, pre / post ductal )( need correct neonatal probes etc )

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Not accepted in UK as part of national screening programme however….

Cochrane review ( 2018 ) showed O2 sats less than 95% significant findingPOS pilot : 231 babies ( 32,836 )8 significant CHD5 non critical CHD82 other diagnoses including sepsis

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Refer to on call paediatrician

( Stockport : Dr Shackley / Dr Wright / refer RMCH cardiology )

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Testes

“About 1 in 100 baby boys have problems with their testes that require an operation”.

Cryptorchidism in 2 – 6 %.

Should be both `down` by 12 months

Bilateral cryptorchidism – refer early

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Bilateral undescended testes should be seen by a senior paediatrician within 2 weeks of the examination

.Persistent unilateral undescended testis:GP to review between 4 and 5 months of agerefer to surgeon if testis still absent to be seen no later than 6 months of age

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Ambiguous genitalia ?

Virilised femaleAt risk of hyponatraemiaUndervirilised maleAt risk of hypoglycaemia

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Other `red flags` for babies

Jaundice < 24hrs, > 14 days, 1st > 7 days

( obstructive : pale stools , dark urine)

( don`t want to miss biliary atresia )

`unwell` eg vomiting, poor feeding, inconsolable crying, pyrexia, lethargic

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`COT DEATH` ADVICE

Back to sleep, feet to footSleep in a cot in parents room 1

st

6 months

Do not fall asleep on sofa with baby

If bed sharing, advise not to if taken alcohol or drugs, smoker or excessively tired ( esp < 11 weeks )Use of a dummy should not be stopped suddenly if accustomed ( 1st

26 weeks )

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Safeguarding children

Need to be alert – no effective screening tool….Poor bonding

Risk factors eg NNU, social, DV

Signs : irritability, limbs, bruises,

#s

BABIES WHO DON`T CRUISE, SHOULDN`T BRUISESeek advice urgently

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Hearing screen ( newborn or by week 5 )

Concerns ? Respond to voice, coos, vocalise ?

? At risk………….refer………

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Posetting babies

Reflux ?CMPI ?

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Any Questions ?