The 6 week check Flashcards
Gross motor development
The neurological control of the infant’s body travels from the top down (caudo-equinal) and the inside out.
If you divide the first 12 months of a child’s life into quarters, you will quite conveniently find the gross motor development roughly progressing down at these points:
- at 3 m a baby should have control of his or her chest
- at 6 m the hips (sitting usually happens at 7–8 m)
- at 9 m the knees (e.g. crawling, bum-shuffling or commando crawling)
- at 1 yr the feet (standing holding on, not necessarily walking).
Gross motor/fine motor milestones
Eyes mostly moving together
Some head control—not flopping everywhere
Symmetrical movements of limbs
Social/speech/communication milestones
Cooing (vowels) emerging
Starting to smile (probably)
Some brief eye contact
Top to toes or vice-versa Ex
Measure the baby’s head circumference, length and weight and plot the velocities.
If there is a risk of the baby crying – listening for a murmur might come first.
If the baby is already crying, hip examination may need to be delayed for a subsequent and more peaceful opportunity.
Initial observations
- Does this baby have a syndrome (eg. Trisomy 21)?
- Does this baby engage with the examiner’s gaze and face in a socially responsive way?
- Are all limbs moving appropriately?
- Is the baby pink, is the baby jaundiced?
- Is there evidence of respiratory distress?
- Do the baby’s eyes follow the examiner’s face as it moves from side to side?
- Do the reflections of the ceiling light remain symmetrical in each eye as direction of gaze changes?
- Is nystagmus present?
- Feel for femoral pulses (which are absent in co-arctation of the aorta)
- Check for descended testes and genital abnormality
- Determine if the hips are stable.
Risk factors of developmental hip dysplasia
Female gender
FHx in a first-degree relative
Breech position at birth
Intrauterine problems:
- packaging (eg. plagiocephaly, torticollis, hyperextended knees, foot deformities)
- reduction in uterine volume (eg. first pregnancy, oligohydramnios, multiple pregnancy)
Wrapping the baby while the legs are straight
The hip examination
- difference in leg length
- knees at different levels when hips and knees are bilaterally flexed
- difficulty in abducting the hip to 90 degrees
- asymmetry of skin folds in the buttocks and posterior thighs when baby is in ventral suspension (the baby is draped over the supporting hand)
Proceed with the Ortolani and Barlow tests for hip dysplasia. (https://www.youtube.com/watch?v=Qn-bWuvm0Pk)
(https://www.youtube.com/watch?v=Qy3uSkDhMZs)
- Examination should not cause the baby any distress.
- Important to describe to parents what and why.
- If any doubt, an ultrasound is the investigation of choice
- Before 6 m, head of the femur is not calcified and so an X-ray is inappropriate.
Barlow test
Detects if a normally positioned head of femur can be dislocated out of a shallow acetabulum.
With one hand, fix the pelvis while the other holds the infant’s leg of the side being examined with the hip in 90 degrees flexion.
With the knee in full flexion, place your fourth and fifth fingers over the head of the greater trochanter.
Apply gentle pressure down toward the couch while feeling if the femoral head drops out over a shallow acetabular edge
Ortolani test
Designed to see if an already dislocated head of femur can be relocated.
By using your fourth and fifth fingers, gently lift toward the roof while abducting the infant’s leg – feeling for a clunk as a dislocated head of femur is slipped over the acetabular edge and into the acetabulum
Heart and lungs Ex
Provided is pink in colour (central cyanosis is always an emergency), not in respiratory distress (ie. no chest recession) and with a normal liver edge, congestive cardiac failure is excluded.
A large VSD or PDA may present with congestive cardiac failure at this age.
Feeding can be a useful symptom when considering SOB in relationship to congenital cardiac issues.
The presence of femoral pulses has excluded co-arctation
Provided the baby is thriving and well there is no urgency to clarify the diagnosis immediately if a murmur is found. A wise clinician will refrain from calling a murmur ‘innocent’ in the first 12 months of life.
Respiratory causes of increased work of breathing may be congenital (eg. an emphysematous lobe) or acquired (eg. chest infection).
Is the parent’s behaviour mutually supportive?
Do the parents hold their baby and talk to their baby in a way that demonstrates they are attuned to the baby’s needs?.
If the answer to ‘what is your baby like to live with?’ is, ‘she’s a joy’, then all that is needed is praise for the parents specific strengths.
If the answer is along the lines of, ‘she’s difficult’, then, although a search is necessary for any possible contributions by the baby to this answer, it is most important to specifically explore the social context.
Possible issues include:
- failure to read and respond to the baby’s social cues
- parental exhaustion
- parental depression
- domestic violence
- substance abuse or other family dysfunction.
The neurological examination
Search for social responsiveness
Some head control—not flopping everywhere
Spontaneously / symmetrical moving all limbs
The development of one side predominant ‘handedness’ before 18 /12 is a red flag for neuromuscular compromise on the less active side.
Hold the baby in ventral suspension:
- Permits inspection of the spine
- Assessment of tone (the head should be held in line with the torso at 6 weeks).
- If the tone is increased or decreased, cerebral palsy and its differential diagnoses should be considered.
Eliciting the primitive reflexes complicates the issue and adds little to the information already gained.
The eyes Ex
Abnormal morphology
Nystagmus
Strabismus
Red reflexes (ie. retinoblastoma, congenital cataracts).
Eyes mostly moving together
The mouth Ex
Check for cleft palate
– a bifid uvula might herald a submucous cleft.
Vaccines
- Rotavirus (start first dose before 15 weeks)
oral vaccine (Rotarix)
- Diphtheria /Tetanus/ Pertussis (DTPa), Polio, Hepatitis B, Haemophilus influenzae type b
injection (Infanrix- hexa)
- Pneumococcal:
injection (Synflorix)
