Tag Archives: 6 week check

FONTANELLES AND HEAD CIRCUMFERENCE AT SIX WEEK CHECK

For General Practitioners, ,

with thanks to Dr Harriet Clompus.

Assessment of fontanelles is an important part of the six week check.  Large fontanelles may indicate a problem in bone ossification or hydrocephaly, while a fused anterior fontanelle can indicate craniosynostosis.  These need to be referred to paediatric outpatients.  Always remember that anterior fontanelle size is very variable (1-4.7 cm in any direction) and always needs to be assessed in context of baby’s head circumference.

A sunken fontanelle indicates dehydration, while a bulging fontanelle indicates raised intracranial pressure (but can be non-pathological – vomiting, crying, coughing – so assess when baby settled!).  These can be discussed with paediatric registrar on-call.

1)      The anterior fontanelle is diamond shaped, 1-4.7 cm in any direction at birth (black infants larger than white) and can widen in first 2 months of life.  Median age of closure is 14 months (4 – 24 months)

 2)      The posterior fontanelle is triangular and is less than 1 cm.  It closes by 6 – 12 weeks.

 

 3)      The size of the fontanelles should always be assessed in conjunction with the head circumference. 

  • Macrocephaly  – familial, hydrocephaly or skeletal disorders such as achondroplasia.
  • Microcephaly  – familial, congenital infections, fetal alcohol syndrome, trisomies

 4)      The quality of the fontanelle  should always be assessed. 

  • Soft fontanelle  – normal
  • Bulging fontanelle – raised intracranial pressure (hydrocephalus, meningitis/encephalitis) .  NB can be non-pathological in crying, coughing or vomiting infant.
  • Sunken fontanelle – dehydration

 

 1)      WIDENED FONTANELLES:  think of…

Achondroplasia

Downs

Hydrocephalus

IUGR

Prematurity

Congenital  Rubella

Neonatal Hypothyroidism (3rd fontanelle)

Osteogenesis Imperfecta

Malnutrition

Rickets/Osteomalacia

 Rickets – Think of rickets in darker skinned, breast fed babies, especially if mothers are veiled.  Infants will often have sweating on the head.  If widened sutures are found check neonatal blood spot for hypothyroidism and refer to outpatients.

 Hydrocephalus – can have widened, bulging fontanelles in conjunction with a large head.

2)      PREMATURE FUSION OF FONTANELLES AND CRANIOSYNOSTOSIS

Closure of anterior fontanelle by six weeks always pathological  (NB  by 3 months 1% of normal infants will have a closed anterior fontanelle). 

Must always assess in conjunction with head circumference – early fusion associated with microcephaly (and less commonly, macrocephaly).

Craniosyntosis is premature closure of cranial suture(s) with skull growth restriction perpendicular to fused suture and compensatory skull overgrowth in unrestricted areas.   Presents with ridging (always pathological beyond one week of life) and abnormal skull shape (usually later than six weeks).

There is a nice background overview (with useful diagrams) to craniosynostosis at http://www.cincinnatichildrens.org/health/info/neurology/diagnose/craniosynostosis.htm.

Primary craniosynostosis is due to abnormal ossification of one or more sutures.  Simple – premature fusion of one suture, complex – premature fusion of multiple sutures.  Causes include rickets, hyperparathyroidism, hyperthyroidism , idiopathic and genetic causes such as Aperts.

Secondary craniosynostosis is caused by premature closure of ALL sutures due to lack of primary brain growth. If you find a child with premature closure of fontanelles or over-riding sutures at six week check you should refer to paediatric outpatients. NB Plagiocephaly (flat occiput) is a non-pathological deformation due to ‘back to sleep’ position – no action required.  It presents with ear on flattened side presenting anteriorly.  Parallelogram shaped head (as opposed to lambdoid suture craniosynostosis trapezoid shaped)

The following articles give lots of information on fontanelles and/or sutures.  The Fuloria article is very thorough and although it focuses on neonatal examination, most of it is still relevant for the six week check.

1) The Abnormal Fontanel, J KIESLER et al Am Fam Physician. 2003 Jun 15;67(12):2547-2552.    http://www.aafp.org/afp/2003/0615/.html  (figure 2 taken from abnormal fontanel)

2)The Newborn Examination: Part I. Emergencies and Common Abnormalities Involving the Skin, Head, Neck, Chest, and Respiratory and Cardiovascular Systems, Fuloria et al, Am Fam Physician. 2002 Jan 1;65(1):61-69.   http://www.aafp.org/afp/2002/0101/p61.html

3) http://www.nice.org/CG037quickrefguide

4) http://www.patient.co.uk/doctor/Examination-of-the-Neonate.htm

5) Craniosynostosis, P Raj et al, emedicine jul 2010 Craniosynostosis : eMedicine Neurology

Neurological examination in babies

For General Practitioners, ,

I have been looking at information on primitive reflexes as I was asked by a GP whether it was significant if he could not elicit a Moro reflex at the newborn check.  Wikipedia has a nice description of the Moro reflex: “it may be observed in incomplete form in premature birth after the 28th week of gestation, and is usually present in complete form by week 34 (third trimester). It is normally present in all infants/newborns up to 4 or 5 months of age, and its absence indicates a profound disorder of the motor system.  An absent or inadequate Moro response on one side is found in infants with hemiplegia, brachial plexus palsy, or a fractured clavicle”.

You need to make sure you are eliciting it correctly first though.  I have found a great site from Utah university with little video clips of aspects of a normal and abnormal neurological examination of a 5 day old.  Take a look at http://library.med.utah.edu/pedineurologicexam/html/newborn_n.html and watch the 2 Moro examples carefully.  Did you know the hands have to come together in the mid-line at the end?

GP version of February 2011’s Paediatric Pearls

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GP February 2011 reminds us all of the NICE guideline on Attention Deficit and Hyperactivity Disorder. We continue our 6-8 week baby check series with information on the absent red reflex and go back to our “from the literature” box to discuss snoring and obstructive sleep apnoea (OSA). We have relaunched our prolonged jaundice guideline. Please leave comments and questions below.

Checking the red reflexes

For General Practitioners, ,

6 week check series – The Absent Red Reflex – with thanks to Dr Sarah Prentice

 Importance of red reflex examination at the 6 week check

Early detection of potentially sight and life-threatening eye disease. Due to the early and time-limited plasticity and development of the eye, any blockage of light to the retina interferes with development of optic neural pathways and can have profound effects on later vision.

 Pathology

                Cataracts

                Retinoblastoma

                High Refractive errors

                Vitreal haemorrhage/opacity

                Corneal scaring (e.g. ocular toxocariasis)

                Retinal tear

                Retinopathy of prematurity

                Persistence of the tunica vasculosa lentis/Persistent hyperplastic primary vitreous (1)

The Examination

                Darkened room

                Ophthalmoscope on +3 dioptres

                Hold 1 foot away

Red reflexes can only be described as normal if they are:                               

Equal in colour, intensity and clarity with no opacities or white spots (2)

 

Handy hints

                For the child that won’t open his/her eyes: try picking/sitting them up or rocking them from sitting to lying.  Having a parent hold them on their shoulder (as if winding them) and looking from behind often works. A feeding child will often open his/her eyes, although breast feeding then makes looking in the eyes logistically tricky.

Children with darker skin tones may have pale retina.  If retinal vessels can be seen and followed to the disc and the reflex is equal bilaterally then this is reassuring.  Comparison with parents’ red reflexes may also help.

Management:

                Normal:   No further follow-up. Will have routine ophthalmology review by school nurse/orthoptist in pre-school years. (5)

                Unable to see red-reflexes or unsure:  Referral to paediatric ophthalmology primary care clinic (if available)

                Absent red reflex:  Urgent referral to paediatric ophthalmologists (should be seen in less than 2 weeks)

                 Family history of neonatal eye disease e.g. retinoblastoma, congenital cataracts:  Routine referral to paediatric  ophthalmologists.

                Low birth-weight/premature infants (at high risk of retinopathy of prematurity):  Should have had ROP screening and follow-up arranged as necessary by neonatal unit.

 References and resources

  1. 1.       Robertson’s Textbook of Neonatology. Fourth Edition. 2005. Edited by Janet M. Rennie.
  2. 2.       American Academy of Pediatrics Policy Statement. Red Reflex Examination in Infants PEDIATRICS Vol. 109 No. 5 May 2002
  3. 3.       Red Reflex Examination in Neonates, Infants, and Children. PEDIATRICS Vol. 122 No. 6 December 2008, pp. 1401-1404 (doi:10.1542/peds.2008-2624)
  4. 4.       www.eyesite.ca/7modules/Module5/html/Mod5Sec1.html  – Good pictures of cataracts, retinoblastoma and glaucoma
  5. 5.       http://www.patient.co.uk/doctor/Vision-Testing-and-Screening-in-Young-Children.htm
  6. 6.       http://www.bartsandthelondon.nhs.uk/docs/poster_red_reflex_print.pdf  Poster of red reflexes and referral pathway from Bart’s and The London.

January GP edition here!

For General Practitioners, PDF digests: for General Practitioners, , , ,

January reminds us all of the NICE guideline on head injury and specifically when a child is supposed to be referred for a CT.  We continue our 6-8 week baby check series with information on undescended testes.  There are also links to agreed blood test reference ranges and resources to help with the identification of asthma inhalers.  Download January 2011 GP PDF here.

Undescended testes

For Emergency Departments, For General Practitioners,

Undescended testes (cryptorchidism) with thanks to Dr Sara Waise

 Occasionally when you are examining a male infant, you may think that one or both of his testes has not yet descended into the scrotal sac.    Infant testes are actually quite retractile; ask parents if they are visible in the scrotum when the baby has a warm bath.  At 6 weeks some babies’ testes may still be palpable within the inguinal canal, especially if they were born a bit early.  Infants with a true undescended testis need to be referred to a paediatric surgeon any time from 6 months of age and definitely by 1 year of age.  Our local paediatric surgery service is at the Royal London Hospital, Whitechapel.

One of the junior doctors, Dr Sara Waise, has put together the following notes on undescended testes for Paediatric Pearls: 

Check whether testes are:

  • Present or absent
  • In the inguinal canal
  • High in the scrotum
  • Able to be brought down into the scrotum

 Identify any other congenital defects 

  • May be isolated
  • Can occur as part of genetic or endocrine disorders and for this reason, my colleague with an interest in endocrinology asked me to remind you that bilateral undescended testes need immediate referral.

 If the testis remains undescended at 1 year of age, referral to a urologist is needed.

 Early correction maximises future fertility potential

  • Outcome is poorer for bilateral undescended testes
  • Unclear whether surgical correction fully normalises this

 Surgical correction reduces malignancy risk

  • Facilitates self-examination
  • Risk remains 5-10 times greater than normal following orchidopexy

 

References

Kurpisz,. M., Havryluk, A., Nakonechnyj, A., Chopyak, V. & Kamieniczna, M. (2010). Cryptorchidism and its long-term consequences. Reproductive Biology 10 19-35

Hutson, J.M., Balic, A., Nation, T. & Southwell, B. (2010). Cryptorchidism. Seminars in Pediatric Surgery 19 215-234

http://www.patient.co.uk/health/Undescended-Testis.htm provides a useful, printable overview for parents of boys in whom you have found an undescended testis. 

http://www.patient.co.uk/doctor/Undescended-and-Maldescended-Testes.htm has information for medical professionals and includes information about the ascending testis syndrome in the older child (around 8 to 10 years old).

December 2010 PDF digest for GPs now published!

For General Practitioners, PDF digests: for General Practitioners, , , ,

December’s Paediatric Pearls (GP edition) reminds us all of the NICE guideline on antibiotic prescribing in respiratory tract infections.  I would like to do a bit more of the “delayed prescribing” in the Emergency Department but it would require either the family coming back (ie. a “no antibiotic” policy really) or their putting a bottle of amoxicillin in their fridge and potentially not using it as we give out the actual antibiotic in A and E, not prescriptions.  We’ve also featured a couple of papers showing that chest x-rays add very little to the management of a child with a respiratory illness which I think most GPs know but it doesn’t harm to remind trainees still in the hospital that, just because the radiology department is at the end of the corridor, it doesn’t mean you have to use it!  We continue our 6-8 week baby check series with information on sacral dimples and I have also put in a couple of websites with sensible, empathetic information and advice on school refusal.  The beginning of term is stressful for children who find it hard to go to school and parents may find these sites helpful when trying to understand why their child is behaving in that way.  Happy New Year to you all!

November’s GP Paediatric Pearls

For General Practitioners, PDF digests: for General Practitioners, , ,

November’s Paediatric Pearls is now published and is available for download here.  It sees the start of our 6 week check series, kicking off with information on heart murmurs.  There is also a bit on bronchiolitis as the season is upon us now and a feature on the NICE guideline on nocturnal enuresis which was published at the end of October 2010.

6-8 week check

For General Practitioners

 The 6-8 week check forms part of a routine set of examinations which are standard practice, although little evidence exists for their efficacy according to http://www.patient.co.uk/doctor/Six-Week-Review-(CHS).htm which is a bit depressing really.  They go on to remind us that 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 advice
  • An opportunity for the parent to express concerns

Many aspects of the check overlap with the newborn check done just after birth.  We are going to be featuring different topics from this child health surveillance check in the GP version of Paediatric Pearls over the next few months, starting this month with heart murmurs (see below).  Please do let us know if there are particular topics you want us to cover by adding a comment below.

Heart murmurs

For Emergency Departments, For General Practitioners,

 

With thanks to Dr Tom Waterfield for his work on this article as part of our series on the 6 week baby check…

The assessment of murmurs can be difficult and identification of the underlying pathology, if any, is best left to a specialist.  For the purpose of the 6 week screening test all murmurs should be referred for further assessment but it is important to identify those children that require urgent assessment from the vast majority that simply require re-assurance and routine referral to a general paediatrician or paediatric cardiologist.

A hypothetical model of heart murmurs in children aged 1 month to 18 years done by an NHS economic evaluation team (http://www.crd.york.ac.uk/CRDWeb/ShowRecord.asp?ID=22002001874) suggested that only approximately 2% of these murmurs would be due to an underlying structural anomaly.   I think the wide age range might undermine this statistic’s relevance to the 6 week check cohort of babies.  A more widely quoted reference from 1998 reports that of 50 healthy term babies with heart murmurs, in 64% the murmur had disappeared by 6 weeks of age.  None of the babies had clinically significant congenital heart disease  and had all disappeared by 6 months of age but one baby had developed a different innocent murmur!  Read the full text of this paper at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1720793/pdf/v078p0F166.pdf.

If a murmur is detected it is important to consider the likelihood of there being significant underlying disease before referring for further assessment and before discussing the murmur with the parents. 

Innocent murmurs are common in children and are associated with normal weight gain, normal feeding and an otherwise normal clinical examination. 

The key points of clinical assessment include:

1)      Assessment of the murmur

  1. Location on the precordium e.g. left sternal edge (Common site of innocent murmurs)
  2. Intensity (1/6 = almost inaudible, 3/6 = audible with a stethoscope, 6/6 easily audible without a stethoscope and associated with a palpable thrill).  Murmurs are more often described now as soft or loud, harsh or musical.
  3. Variability with position – a feature of innocent murmurs (but not something one necessarily notices at the 6/52 check)
  4. Diastolic Vs Systolic – diastolic murmurs should always be treated as pathological

2)      Assessment of perfusion

  1. A pink child with a capillary refill time <2 seconds and with good peripheral pulses (including femoral pulses) is less likely to have significant heart disease
  2. Absent femoral pulses may represent coarctation of the aorta
  3. Cyanotic heart lesions rarely present outside the immediate perinatal period 

3)      Assessment for signs of heart failure

  1. Failure to thrive and recurrent respiratory infections
  2. Respiratory distress with hepatomegaly.  Crackles are not really heard in heart failure in infants
  3. Peripheral oedema and a raised JVP are NOT features of heart failure in this age group and their absence is not reassuring

If a child has a soft systolic murmur at the 6 week check and is growing well and feeding normally with an otherwise normal examination the child can be referred routinely to paediatric outpatients and the parents reassured that the murmur is likely to be due to the normal flow of blood around the heart.  If there are any worrying features then the child should ideally be discussed with the paediatric registrar on call and the appropriate referral or admission discussed.

References

The British Heart Foundation has a factfile sheet for GPs on heart murmurs in children but it is not downloadable from http://www.bhf.org.uk because it is over 5 years old and they worry that their old factsheets may go out of date.  BHF have however very kindly sent it to me and allowed me to upload it on to this site as an educational resource.  Download it here.

http://www.patient.co.uk/doctor/Heart-Murmurs-in-Children.htm would be a good resource except that it still talks about antibiotics for children with heart defects when they have dental treatment and we gave up doing that in 2008 after NICE said it wasn’t necessary (http://www.nice.org.uk/nicemedia/live/11938/40014/40014.pdf).

http://www.tinytickers.org is a parental support website concerned primarily with antenatal diagnosis and screening.

http://kidshealth.org/parent/medical/heart/murmurs.html# is one of the top American sites on children’s health aimed at the general public.  It provides balanced information in clear English about heart murmurs for parents who are worried that their GP has picked up a heart murmur incidentally on examining their child.  Our outreach cardiologist has written a few words on innocent heart murmurs too at http://www.kidscardiologist.com/conditions/innocent-murmur.html.

If your patient does turn out to have congenital heart disease, http://www.rch.org.au/cardiology/defects.cfm?doc_id=3011 is a fantastic site from Melbourne’s Royal Children Hospital with lovely clear diagrams and explanations of different morphological anomalies.