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The eight-week check

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The eight-week baby check, usually carried out in primary care, provides an opportunity to assess a baby’s development, screen for potential issues, and address any concerns parents or guardians may have. NICE Guideline NG194 from 2021 covers in fine detail what should be done.

Let’s walk through the key steps and considerations when performing an eight-week baby check, including what to note, what to review and what to refer. 

The eight-week baby check is an important child health surveillance milestone to ensure the well-being of the infant and detect any potential health issues that may have arisen since the initial newborn check.

Review the Medical Records 

Before beginning the consultation, take some time to review the baby’s medical records. This includes checking the discharge letter from the hospital for any complications during pregnancy or birth.

Additionally, look for any previous visits to the GP, focusing on safeguarding concerns or community healthcare inputs from health visitors or community midwives. Look for any concerns about feeding, bowels, or sleep.

It is helpful to do this before calling the family in from the waiting area – whilst this appointment is all about the baby, it is important to have a sense of how the birth went.

Be mindful that not all babies have two parents of opposite genders, and some children may be in the care of a foster carer, so establish who they will be attending with and ensure you know who they are and do not make assumptions about their identity.

Review the Red Book 

The “Red Book” (UK) is a comprehensive logbook that accompanies the baby from birth and contains critical information, including newborn screening results, immunisation records, centile charts for height and weight, and notes from community healthcare professionals.

Pay special attention to milestones, as parents often refer to this section for guidance. Check that the baby has had their weight and head circumference checked and plotted on the growth chart. Remember that crossing centile lines is a reason to review, and crossing two centile lines in either direction usually means referral.

Including caregivers in the examination process is crucial, especially for first-time parents. Explain what is going to happen and explain your findings as you go.

You shouldn’t rush in with the physical exam. Start by asking the parent or caregiver about any concerns or questions they may have about their baby’s growth, development or bodily functions. 

Watch the interaction between the baby and the parents or caregivers. Assess the baby’s responsiveness, such as smiling, startle reflex to auditory stimuli, and curiosity. Ensure that the baby is following movements and engaging with their surroundings.

The Red Book suggests a top-to-toe structure for the exam. This can work well, though, in reality, it is often helpful to take an opportunistic approach and listen to the heart first before the crying starts. 

Position yourself on both the right and left sides of the baby to observe neck movement and overall flexibility. If the baby is quiet and happy in their caregiver’s arms, I usually listen quickly to their heart sounds before starting to undress them in case they get upset later and will not quieten. If the baby is asleep, try to listen to their heart sounds, as newborns may have murmurs that are challenging to detect. 

The head

Check for bilateral red reflexes and look for the baby fixing and following your light source. If you are struggling to get the baby to open their eyes, ask the caregiver to hold them up over their shoulder and be patient.

Look at the ears and check for any preauricular pits or accessory auricles.

Palpate their anterior fontanelle. It should still be open before four months of age. Most are closed by fourteen months, though up to 26 months is considered normal. Palpate the sutures of the skull. Look for asymmetry of the skull or any signs of premature closure of fontanelles or bulging of sutures. If there are any concerns about craniosynostosis, refer them urgently. A degree of positional plagiocephaly is common and not abnormal. 

Examine the mouth, looking with a torch for a cleft palate and palpating with a gloved finger for any defect. If the parent has any concerns about latching, look for a tongue tie, though management of these is controversial unless this is seriously affecting feeding or weight gain

The chest and abdomen

Now, it’s time to ask the caregiver to strip the baby down to their nappy.

Start by listening to their heart sounds and then auscultate the lungs.

Examine the baby’s body, particularly checking for any asymmetry or birthmarks and ensure the umbilical cord stump has fallen off or is being treated appropriately if it’s still there. Umbilical granulomata are common, though they have usually resolved by eight weeks. Look for umbilical hernias – these need recording in the notes but will almost always resolve by 4-5 years old and do not usually need surgical correction. Palpate the abdomen to check for any organomegaly. 

Inspect the genitals. In boys, check for hypospadias, which may have been missed at the newborn check and palpate the testes to ensure they are palpable in the scrotum. Be cautious when exposing a boy to cold air; use the nappy as a shield; otherwise, you will get sprayed. 

The arms and legs

Check hands and feet and count digits. Look for any deformity of the feet or hands remembering that positional talipes identified at a newborn check should have resolved by now.

Hold and gently move the baby’s arms and legs up and down to assess limb tone. Look for any signs of increased or decreased tone.

Perform a thorough examination of the baby’s groin, checking for hernias and assessing femoral pulses on both sides. Use your thumb or index finger to locate the femoral pulse. 

The hips

Examine the hips. Start by looking for any asymmetry of the hip creases or leg length. Then, perform the two special tests for hip instability/dysplasia.

Barlow’s Test 

  • Adduct the hip, then apply a downward pressure over the knee with your thumb. 
  • If the hip is unstable, the femoral head will slip out of the acetabulum, producing the palpable sensation of the hip dislocating. 
  • If the hip is dislocatable, then Barlow’s test is positive.

Ortolani’s Test

  • Used to confirm the hip dislocation. 
  • Flex the hips and knees to 90 degrees, then apply anterior pressure over the greater trochanter and gently adduct the leg with your thumbs. 
  • If the hip is dislocated, a distinctive clunk will be heard as the hip relocates. This would be Ortalani’s test positive.

After examining the hips, turn the baby prone and examine the spine for clefts, pits or marks.

Inspect the anus for position, then replace the nappy.

The Moro reflex

If the child has not yet cried, now’s your chance. It’s time to check the Moro reflex or startle reflex.

Hold the baby supine on your arm with your elbow resting on the examination couch arm at 45 degrees. Suddenly, drop your hand backwards 20 degrees and look for symmetrical abduction and immediate adduction of the arms.

It is important to tell the parent what you are going to do so they don;t think you are going to drop their precious bundle of joy.

Finishing off

At the end of the examination, encourage the parents to dress the baby and write their findings in their electronic and hand-held records. If a referral is needed, try and do it straight away.

Then, it’s time for their eight-week immunisations.

Six Week Check

A poem by Dr Emma Storr 

I wake you. Unpeel your clothes 
to hold you naked in my hands. 
You look surprised at being new. 
I murmur nonsense while I note 
your symmetry and serious gaze, 
the texture, tone and feel of you. 

Your brain is heavy, busy growing 
like a walnut in its shell. 
Your fontanelles are soft to touch. 
I auscultate your rapid heart, 
impatient, tapping at your ribs. 

You startle in expected ways: 
fling your arms, reflexes brisk. 
You turn to noise. Each orifice 
is present, patent, hard at work. 

I hand you back to anxious arms, 
catch your baked cub-like scent. 
I circle ‘normal’ on my list. 
You yawn and fall back into dreams, 
unaware you’ve passed my tests. 
We won’t need to meet again.

References

NICE Guideline NG194 2021 Postnatal Care 

https://www.nhs.uk/conditions/umbilical-hernia-repair/

https://www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/neonatology/postnatal-handbook/postnatal-handbook-qeuh/hip-examination-and-referrals/

Author

  • Dr Tara George. MBChB (Hons) Sheffield 2002, FRCGP, DCH, DRCOG, DFSRH, PGCertMedEd Salaried GP and GP Trainer, Wingerworth Surgery, Wingerworth, Derbyshire. GP Training Programme Director, Chesterfield and the Derbyshire Dales GP Speciality Training Programme. Out of Hours GP and supervisor, Derbyshire Health United. Early Years Tutor, Phase 1, Sheffield University Medical School. Mentor, GP-s peer mentoring service and Derbyshire GPTF new to practice scheme. External Advisor RCGP. Host Bedside Reading podcast. Pronouns: she/her When she's not doing doctory things Tara loves to bake, to read novels, run and take out some of that pent up angst in Rockbox classes.

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