The first scheduled examination in child health surveillance (CHS) is the six-week check. This forms part of a routine set of examinations which are standard practice, although little evidence exists for their efficacy.¹ It should take place by eight weeks at the latest and should include:

• A physical examination
• A review of development
• An opportunity to give health promotion advice²
• An opportunity for the parent to express concerns

Physical examination

The main purpose of this is to detect:

• Congenital heart disease
• Developmental dysplasia of hip (previously known as congenital dislocation of hip)
• Congenital cataract
• Undescended testes

It should also include:

• A weight check
• Measurement of head circumference (and opportunity to palpate sutures and fontanelles, and assess head shape)
• Assessment of tone
• Check of spine, genitals, femoral pulse, hernias and palate
• Observation for and exclusion of jaundice, organomegaly and dysmorphic features

Heart disease

Congenital heart disease (CHD) is the most commonly notified malformation; in 2001 there were 1,014 notifications of CHD among live births.³ Early detection and treatment often improves long-term outcome. The six week check could be the first time a murmur is heard; a ventricular septal defect (VSD) may have no signs in the first 24 hours when the baby check was done. Also some heart defects may not cause symptoms until irreversible pulmonary hypertension develops.

• Look for cyanosis, ventricular heave, respiratory distress, and tachypnoea; a respiratory rate persistently over 55 is suspicious. The rate should not be >30 when asleep, if older than 4 weeks.
• Feel for apex beat and assess whether displaced.
• Listen for murmurs. Innocent murmurs are common and are typified by low intensity, localised to a small area of praecordium and in the absence of other symptoms or signs. If in doubt, refer.

Developmental dysplasia of the hip (DDH)

In 2001 there were only 136 notifications of DDH.³ The general approach is to:

• Check for leg-length discrepancy
• Check for asymmetry of leg creases
• Perform Barlow and Ortolani tests

Refer promptly if any abnormality is detected. Treatment commenced within 6-8 weeks is often successful, but a missed diagnosis can be devastating.
Risk factors for DDH include:

• Family history
• Breech presentation
• Feet abnormalities
• Torticollis

An ultrasound scan of the hips is performed a few days after birth for neonates who have risk factors. However, it is unlikely to become a universal screening test.
Barlow's test identifies hips which are dislocatable:

• Examine one hip at a time with the baby lying supine.
• For the left hip, support the pelvis with your left hand.
• With your right hand, flex and adduct the left hip. (Keep your fingertips on the greater trochanter laterally and your thumb on the medial proximal thigh).
• Gently push the hip posteriorly in the line of the shaft of the femur.
• A positive test causes the femoral head to slip out of the acetabulum which you can feel.
• Do the 'mirror image' for the right hip.

• Examine one hip at a time with the baby lying supine.
• Hold the hip as in the Barlow test.
• Gently abduct the hip fully until it lies flat on the bed.
• If the hip is dislocated you can feel, and sometimes hear, a 'clunk' as the femoral head goes back into the acetabulum during abduction.

Eye examination

109 eye anomalies were reported in 2001, of which anophthalmia accounted for 20.
The Royal College of Ophthalmologists' guidelines⁴ suggest that:

• The external eyes should be examined; this may suggest conditions, e.g. glaucoma, which may be indicated by one eye being larger than the other.
• The presence of a red reflex in each eye should be established; hold an ophthalmoscope about 30 cm from the infant's eyes. Dark spots in the red reflex can be due to cataracts, corneal abnormalities, or opacities in the vitreous.
• The parents should be asked if there is a family history of visual disorders, particularly retinoblastoma or congenital cataract.
• Parents should be asked soon after birth (and at each subsequent contact) whether they have any anxieties about the baby's vision.

If there any doubts as a result of this, an urgent referral should be made to hospital ophthalmic services.

Testes

Check that both testes are well down in the scrotum. Refer if there is doubt.

Tone

• When held in ventral suspension, the baby should be able to hold their head in line with the rest of their body.
• When pulled to sit from supine, there will be some head lag, but there should be some ability to raise the head.

Review of development

• Review feeding and weight gain.
• Check growth chart.
• Review vision and hearing; automated hearing screening is being phased in for neonates.⁵ But, ask parents if their child can see and hear. Most parents will have noticed that their baby will 'still' to sudden noise and will follow a face with their eyes.
• Socially; most babies will be spontaneously smiling by 6 weeks. Also, they will have a range of sounds - coos, glugs, cries - which indicate mood.

Ask the parents if they have any other concerns.

Health promotion

This is also an opportunity to discuss:

• Immunisations
• Breast-feeding and other advice on feeding and weaning^6,7
• Reducing the risk of sudden infant death syndrome⁸
• Dangers of passive smoking
• Car safety and other injury prevention strategies
• Dental health; sugar-free medicines, avoiding sugary drinks or sugar on dummies⁹

Give written advice where appropriate.
Also, briefly consider maternal health. In particular, is there evidence of postnatal depression? Consider the involvement of the father and use the opportunity to involve him in the care of the child.²

Document references

1. Dinkevich E, Hupert J, Moyer VA; Evidence based well child care. BMJ. 2001 Oct 13;323(7317):846-9.
2. Healthy Child Programme: pregnancy and the first five years of life, Department of Health (October 2009)
3. National Statistics. Congenital Anomaly Statistics notifications - 2001: England and Wales - summary table.; 2001
4. RCOphth.; Ophthalmic Services for Children. Published 2005.
5. National Library for Health; Newborn Hearing Screening - well baby protocol - Map of Medicine; [As PDF]
6. Oddy WH; Breastfeeding protects against illness and infection in infants and children: a review of the evidence. Breastfeed Rev. 2001 Jul;9(2):11-8. [abstract]
7. Leung AK, Sauve RS; Breast is best for babies. J Natl Med Assoc. 2005 Jul;97(7):1010-9. [abstract]
8. Foundation for the Study of Sudden Infant Deaths. Advice for professionals.
9. Harris R, Nicoll AD, Adair PM, et al; Risk factors for dental caries in young children: a systematic review of the literature. Community Dent Health. 2004 Mar;21(1 Suppl):71-85. [abstract]

Internet and further reading

• Hall DMB; Health for All Children. 3rd edn. Oxford: Oxford Medical Publications 1996.
• UK National Screening Committee; Newborn and 6-8 week Infant Physical Examination Digital Toolbox
• UK National Screening Committee; Child Health Screening Subgroup

Acknowledgements