Dr Jennifer Parkhouse describes the essential elements of the 6–8-week baby check and how risk factors and concerns of parents/carers also need to be considered

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Read this article to learn more about:

  • the NHS newborn and infant physical examination screening programme
  • how to carry out the check
  • how and when to refer and referral timeframes.

The 6–8 week baby check is a comprehensive examination normally performed by a GP in the community. The examination is often undertaken at 8 weeks to coincide with the time of the baby’s first vaccinations. It is important not only for picking up any potential abnormalities but also to address any concerns that the parent/carer may have regarding their child. The 6–8‑week examination is exactly the same as that performed on a newborn baby at hospital, or at home if delivered there. Some abnormalities that were not apparent at 72 hours after birth can become apparent by the time of the 6–8-week check.

The examination essentially entails a top-to-toe examination of the baby. In 2008, the UK National Screening Committee set up national standards for the examination of newborns and infants. This is the NHS newborn and infant physical examination (NIPE) screening programme.1 The screen should be performed within 72 hours of birth and then again at 6–8 weeks. The programme’s main aim is to identify and refer all children born with congenital abnormalities of the eyes, heart, hips, and testes. Any antenatal and postnatal risk factors should also be assessed at each stage of the check. See Figure 1 for the NIPE infant screening pathway.1

Figure 1: NIPE screening programme: infant pathway

flow chart nipe screening programme infant pathway

Source: Public Health England (PHE). Newborn and infant physical examination screening programme handbook—2016/17. London: PHE, 2016. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/572685/NIPE_programme_handbook_2016_to_2017_November_2016.pdf
Reproduced under the Open Government Licence for public sector information

General health

Within the first 6–8 weeks, the baby should have been weighed and seen several times by a midwife/health visitor. It is important to check the centile chart to monitor the baby’s growth and to enquire whether there have been any concerns over this time period. It is also important to ask if there were any concerns with the first baby check that need to be addressed at the 6–8‑week examination. If the child was due to have an ultrasound of their hips, ensure that this has been done or that they have an appointment booked. Likewise, if the infant is due to be seen by a specialist for some reason, ensure that they have an appointment booked.

Parents and carers may take the opportunity to raise common problems (e.g. reflux, colic, wind, feeding problems, sleep problems). If you are aware of all the concerns before the examination, you can ensure that you address all the parental needs.

Enquire specifically if there is any family history of eye, heart, or hip problems, more of which will be discussed later.

Examination

Although there are four key areas that require screening, the baby check does involve a full examination. NICE Clinical Guideline 37 on Postnatal care up to 8 weeks after birth specifies in detail the physical examination that should be carried out (see Box 1).2

Box 1: Physical examination and screening2

This should include checking the baby’s:

  • appearance including colour, breathing, activity, and posture
  • head (including fontanelles), face, nose, mouth including palate, ears, neck, and general symmetry of head and facial features. Measure and plot head circumference
  • eyes—check opacities and red reflex
  • neck and clavicles, limbs, hands, feet, and digits—assess proportions and symmetry
  • heart—check position, heart rate, rhythm and sounds, murmurs, and femoral pulse volume
  • lungs—check effort, rate, and lung sounds
  • abdomen—check shape and palpate to identify any organomegaly; also check condition of umbilical cord
  • genitalia and anus—check for completeness and patency and undescended testes in male
  • spine—inspect and palpate bony structures and check integrity of the skin
  • skin—note colour and texture as well as any birthmarks or rashes. [This can be particularly important if a child has a Mongolian blue spot, so that if this is seen at a later date it is not mistaken for a bruise3]
  • central nervous system—observe tone, behaviour, movements, and posture. Elicit newborn reflexes only if concerned
  • hips—check symmetry of the limbs and skin folds (perform Barlow and Ortolani’s manoeuvres)
  • cry—note sound
  • weight—measure and plot2 [this will usually be done by the health visitor].

Adapted from: National Institute for Health and Care Excellence. Postnatal care up to 8 weeks after birth. NICE Clinical Guideline 37. NICE, 2015. Available at: www.nice.org.uk/cg37

NICE has not checked the use of its content in this article to confirm that it accurately represents the NICE publication from which it is taken.

This is the same examination as that carried out within 72 hours of birth with the addition that at the 6–8‑week check the parents/carer should be asked if the child is smiling and fixing and following, if not obvious at the examination.2

Eye examination

Two or three in 10,000 babies have problems with their eyes that require treatment. The main aim of the examination is to detect congenital cataracts.1 Therefore parents should be asked about any family history of congenital or hereditary cataracts. The infant’s eyes should be assessed for:1

  • symmetry and position
  • size and colour
  • presence of red reflex
  • eye movement, including whether the child is fixing and following. 

Absence of any reflex suggests congenital cataracts. Other eye issues may well be detected, such as white reflex, which is suggestive of retinoblastoma.1 Any abnormalities should prompt a referral to an ophthalmologist and the infant should be seen by 11 weeks of age.1

Heart examination

Approximately 4–10 in every 1000 babies have a congenital heart defect.1 The main risk factors include family history of congenital heart disease, trisomy 21 or other trisomies, or a cardiac abnormality suspected at antenatal screening.1 Specific questions to ask the parent/carer include:1

  • does the infant ever get breathless or change colour at rest or with feeding?
  • are the infant’s feeding behaviours and energy levels normal?
  • is the baby ever too tired to feed, quiet, or lethargic, does s/he have poor muscle tone?

If any positive findings are found (such as a murmur), the examining practitioner should discuss findings with a senior paediatrician with expertise in cardiology, and refer as appropriate. The urgency of the referral will depend on the clinical condition of the baby.1

Hip examination

Approximately 1 or 2 in every 1000 babies have a hip problem requiring treatment.1 The hip examination is designed to pick up those infants with congenital dysplasia of the hip. Delay in diagnosis can cause significant issues, such as osteoarthritis, pain, and impaired mobility.1 See Box 2 for NHS NIPE programme risk factors for hip problems in babies.

Box 2: NHS newborn and infant physical examination (NIPE) programme: risk factors for hip problems in babies1

  • First-degree family history of hip problems in early life, that is, baby’s parents or siblings who have had a hip problem that started as a baby or young child that needed treatment with a splint, harness, or operation
  • Breech presentation at or after 36 completed weeks of pregnancy, irrespective of presentation at delivery or mode of delivery, or breech presentation at delivery if this is earlier than 36 weeks
  • In the case of a multiple birth: if any of the babies is breech presentation, all babies in the pregnancy should have an ultrasound examination within 6 weeks of age. [The rationale for this advice is that if one of the babies meets the criteria of breech presentation, as described above, it may be difficult to accurately identify which baby was affected.]

Public Health England (PHE). Newborn and infant physical examination screening programme handbook—2016/17. London: PHE, 2016. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/572685/NIPE_programme_handbook_2016_to_2017_November_2016.pdf

Reproduced under the Open Government Licence for public sector information

Screen for positive signs; these include:1

  • 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 (in ventral suspension the baby is draped over the supporting hand)
  • palpable clunk when undertaking either the Ortolani or Barlow manoeuvre:1
    • the Ortolani manoeuvre is used to screen for a dislocated hip
    • the Barlow manoeuvre is used to screen for a dislocatable hip.

If the screen is positive at the 6–8‑week check, refer the baby directly to an orthopaedic surgeon for urgent expert opinion (to be seen by 10 weeks of age).1

Examination of testes

Approximately 1 in 100 baby boys has problems with their testes that require treatment.1 If at the 6–8‑week check an infant is found to have bilateral undescended testes they should be seen by a paediatrician within 2 weeks of the examination. For a persistent unilateral undescended testis, the GP should review at 4–5 months of age and refer the infant to a surgeon if the testis is still absent (not to be seen later than 6 months of age).1

Missed examinations

The parents of a child who misses the 6–8‑week baby check should be contacted to arrange an appointment (if they do not already have one) as soon as possible. It is also advisable to contact the child’s health visitor to make them aware of the delayed examination and to find out if there are any concerns relating to the baby or family. The Ortolani and Barlow tests are no longer reliable once the baby is more than 3 months of age. Any asymmetry of leg length or hip abduction should therefore be checked, as well as gait if appropriate.1

Training

No additional formal training is required to perform the 6–8‑week examination. However, it is the healthcare professional’s responsibility to ensure their skills are up to date. There are eLearning modules available to support GPs in improving their knowledge:

References

  1. Public Health England (PHE). Newborn and infant physical examination screening programme handbook—2016/1 7. London: PHE, 2016. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/572685/NIPE_programme_handbook_2016_to_2017_November_2016.pdf 
  2. NICE. Postnatal care up to 8 weeks after birth. NICE Clinical Guideline 37. NICE, 2015. Available at: www.nice.org.uk/cg37
  3. Great Ormond Street Hospital. Mongolian blue spots. www.gosh.nhs.uk/medical-information-0/search-medical-conditions/mongolian-blue-spots (accessed 5 June 2017). G