The 6 week check

Hannah ShoreConsultant Neonatologist

Leeds

Plan

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

Why do it?

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

What info do you need?

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

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/

Screening Summary:

9newbornphysical.screening.nhs.uk/

If no referral or risk factors - indicated in GREEN

Pop up Form: entering Referral Data

Referrals highlighted in RED

Printing options

10newbornphysical.screening.nhs.uk/

S P O T R N

S P O T R N

Last Name: Thomas Place of Birth: Hospital

First Names: Baby Date of Birth: 05/11/2012 (12:00:00)

NHS No: Unit No: 1234 Length of pregnancy: 40 Address: 1 The Road, The town, , ,

Type of delivery: Mother’s NHS Number: Gender: Male Problems during

pregnancy, birth or neonatal period:

GP:

Health Visitor: Admitted to NICU: No Yes, for Days

Birth Weight: 3500 g Length: cm

Head circumference:

Hips Barlow and Ortolani tests on both

L Unilateral Abnormality Suspected (Right) with No Risk Factors

Notes:

R

Testes Ring ‘N’ for girls L

No Abnormalities Notes:

R

Eyes Includes inspection and red reflex

L No Abnormalities & No Risk Factors

Notes:

R

Heart Colour, pulses, heart sounds, murmurs

No Abnormalities & No Risk Factors

Notes:

Rest of Physical Examination

Includes fontanelle, palate, spine, heart, abdomen, urine system, passage of meconium

No Abnormalities

Notes:

Location of screening session: Hospital Facility of screening session

(if Hospital): NIS_Training A1

Date Performed: Feb 15 2013 3:29PM Performed By: Clare Jones Signature:

Head

• What should you look for?

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

Eyes

• What are you assessing?

Eyes

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

Risk factors

• <32 weeks <1500g• FH• Maternal infection• HSV

Eyes

• What pathology may you find?

Eyes

• Cataract• Retinoblastoma• Coloboma

Cataracts

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

Retinoblastoma

• Leukocoria – absent red reflex

• 1:20,000

Coloboma

Any abnormality

• Refer URGENTLY to ophthalmology

• Each 3 week delay leads to drop in snellen acuity by one line

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

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

Questions to ask parents?

Questions to ask parents?

• Breathless on feeding• Slower to feed• Colour change• Increased resp rate

Cause of concern

• Tachypnoea• Apnoea and colour change• Resp distress• Cyanosis• Visible pulsations• Murmurs• Absent/ weak femorals

• REFER at time of examination

Examination

• Observation• Palpation – pulses, heaves, thrills• Cap refill time

• ? Saturation monitoring

Examination

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

VSD

• Classically presents at 6 week check• Drop in PVR – shunt occurs• Often presents in failure

• Other pathology

Coarctation of aorta

Hypoplastic left heart

Hips

• Developmental Dysplasia of the hips

• Progressive condition• Easy to miss• Needs regular checks

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

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

What are the risk factors?

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

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

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

Alpha angle

Ileum

Acetabular roof

Dysplastic

Dislocated

Types of problems

• Dysplastic• Low dislocation• High dislocation

Examination

• Full range of hip movement?• Symmetrical knees when flexed• Leg creases• OrtoLani – disLocated

– Try and relocate• Barlow – dislocataBle

– Try and dislocate

Discussion with parents

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

If test abnormal

• Refer directly for urgent expert opinion• USS to be done

• To be seen by 10 weeks of age

Treatment

• Pavlik harness– Rash, femoral nerve palsy, pressure sores

• Surgical reduction of the femoral head

• Needs long term follow up regarding actual outcomes

Practical bit….

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

Examination

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

What to do?

• Bilateral 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?

Cleft palate

• Can be hard to diagnose

Neurology / development

• Fix and follow• Head held in line in ventral suspension• Symmetrical moro• Smiles

Summary

• Review of 6 week check• Key areas

– Eyes– Heart– Hips– Testis– Cleft palate

• Introduced concept of NIPE• http://newbornphysical.screening.nhs.uk