6-week check

The standard structured infant examination performed around 6 weeks of age.

Before you start

Elicit parental concerns directly — feeding, immunisations, development, and social/relationship functioning (“what is your baby like to live with?”). Starting with head circumference, length and weight is a good way to engage with the baby while asking parents questions. Some parts of the exam are best done opportunistically (e.g. auscultating for murmurs, the hip exam) rather than in a fixed order.

Observation

• Parent–child interaction — pay particular attention to the parents’ perception of life with the baby, and the bond between them.
• General appearance — symmetry of limb movement; facies (e.g. trisomy 21, fetal alcohol syndrome); colour (plethora, jaundice); respiratory distress; does the baby engage with your gaze/face and fix-and-follow it side to side?
• Femoral pulses — absent in coarctation of the aorta.

Hips (DDH screening)

Risk factors: female, family history, breech position, first child, twins, oligohydramnios, other tendon problems (club foot, torticollis).

• Abduct both hips simultaneously — symmetrical abduction is reassuring.
• Barlow test — attempts to dislocate a located femoral head (push down from 90° flexion).
• Ortolani test — attempts to relocate an already-dislocated femoral head.
• If any doubt, organise ultrasound between 6 weeks and 4 months; X-ray once older than 4 months.

Abdomen

Exclude organomegaly (occasionally feeling the spleen tip, or a liver edge 2–4 finger-widths below the costal margin, is normal) — looking for signs of congestive cardiac failure or a congenital metabolic/storage disease.

Heart and lungs

• If the baby is pink, not in respiratory distress, and has a normal liver edge, congestive cardiac failure is excluded (e.g. from a large VSD/PDA).
• Ask about breathlessness while feeding.
• Check for murmurs — reasonable to watch and wait if the child is otherwise well and thriving; if concerned, a routine (non-urgent) cardiac echo can be arranged. See murmurs in childhood.
• Femoral pulses (if not already checked) exclude coarctation of the aorta.

Neurological examination

• Assess the spine and limb movement; hold in ventral suspension — the head should be held roughly in line with the torso at 6 weeks. Increased or decreased tone raises the possibility of cerebral palsy.
• A preference for one side (handedness) before 18 months is a red flag for a neurological deficit.
• Eliciting primitive reflexes adds little diagnostic value.

Eyes

Check morphology, symmetrical light reflex on directional gaze (nystagmus, strabismus), and the red reflex.

Mouth

Check for cleft palate — a bifid uvula can be a sign of a submucous cleft.

Genitalia

Check for descended testes and any genital abnormality.

Hot tips

• Oral thrush shows as white material stuck to the cheek — a white tongue alone is not thrush.
• Fontanelle closure can occur anywhere from 4 to 26 months.
• An open fontanelle allows ultrasound assessment if increased head growth velocity raises concern for hydrocephalus.
• Flat occiputs (plagiocephaly) are commonly found and usually resolve spontaneously — but a head shape becoming progressively more distorted suggests craniosynostosis. See paediatric head shape.
• Growth: some babies are born smaller or larger than their genetic potential — interpret growth velocity in light of parental size; probably fine if all three growth parameters (length, weight, head circumference) are trending in the same direction.