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PEDIATRIC SCREENING - Complete Step-by-Step Guide with Viva Questions

DEFINITION

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PART 1: THE WELL-CHILD VISIT FRAMEWORK

General Principles Before You Begin

1. Build rapport first - approach the child slowly; do NOT rush to touch immediately
2. History before examination - observe spontaneous activity during history-taking
3. Start with the least distressing parts - cardiac and respiratory examination first when the child is quiet; ear and throat examination LAST
4. Use the parent as an ally - for children 8 months to 3 years, examine on the mother's/parent's lap
5. Warm your hands before touching; introduce equipment as toys for young children
6. Every part of the child must be undressed and examined at some point

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PART 2: STEP-BY-STEP PEDIATRIC SCREENING EXAMINATION

STEP 1: Vital Signs and Anthropometry

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STEP 2: Growth Assessment and Plotting

1. Use WHO growth charts (0-5 years) and CDC growth charts (2-20 years)
2. Plot all 4 parameters: weight-for-age, height-for-age, weight-for-height/BMI-for-age, head circumference-for-age
3. Assess for:
   • Failure to thrive: weight-for-age <3rd percentile OR crossing 2 major centile lines downward
   • Short stature: height <3rd percentile
   • Microcephaly/Macrocephaly: head circumference below 0.4th or above 99.6th percentile (RED FLAG at any age)

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STEP 3: Developmental Screening

AAP-Recommended Schedule:

• Developmental surveillance - every well-child visit
• Formal standardized screening - at 9 months, 18 months, and 30 months (or 24 months if 30-month visit not feasible)
• Autism-specific screening (M-CHAT-R/F) - at 18 months AND 24 months

Denver Developmental Screening Test II (DDST-II) - 4 Domains:

• Normal - no delays, at most 1 caution
• Suspect - 2 or more cautions OR 1 delay
• Untestable - child refuses items

Key Developmental Milestones (from Harriet Lane Handbook):

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STEP 4: Developmental Red Flags (MANDATORY to Know)

• Loss of previously acquired skills (regression) - ALWAYS a red flag
• Parental concern about vision or hearing
• Persistently low muscle tone
• Asymmetry of movements (suggests cerebral palsy)
• Head circumference crossing 2 major percentile lines

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STEP 5: Neonatal/Newborn Screening

• Apgar Score at 1 and 5 minutes (Heart rate, Respiratory effort, Muscle tone, Reflex irritability, Color - 0-2 each, max 10)
• Cord blood (10-15 mL): saved for 7 days for blood typing, Coombs' test, other tests as needed

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STEP 6: Vision Screening

• 20/200 at 6 months
• 20/40 at 1 year
• 20/20 by 5-6 years

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STEP 7: Hearing Screening

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STEP 8: Autism Spectrum Disorder (ASD) Screening

• Age: 16-30 months
• Completed by: Parent (20 yes/no questions)
• Scoring:
  • 0-2: Low risk
  • 3-7: Medium risk - proceed to structured follow-up interview
  • 8-20: High risk - immediate referral to developmental specialist

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STEP 9: Cardiovascular Screening

• Sports pre-participation screening: AHA 12-element history and physical (personal history of exertional chest pain, syncope, unexplained fatigue, prior heart murmur, hypertension; family history of sudden cardiac death <50 years)
• Routine ECG is NOT required unless cardiac disease is suspected
• Blood pressure screening starts routinely at age 3 years

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STEP 10: Other Routine Screenings

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STEP 11: Systematic Head-to-Toe Physical Examination

1. General appearance - ill/well, nutritional status, dysmorphic features
2. Skin - color (jaundice, pallor, cyanosis), rashes, Mongolian spots, neurocutaneous markers (cafe-au-lait spots, ash-leaf spots, port-wine stain)
3. Head - fontanelles (anterior closes 12-18 months; posterior closes 2-3 months), craniosynostosis, skull shape
4. Eyes - red reflex, strabismus (Hirschberg test), visual acuity, discharge
5. Ears - low-set ears (renal anomalies, Down syndrome, FAS), otoscopy (tympanic membrane, light reflex)
6. Nose - nasal flaring, discharge, choanal atresia
7. Mouth/Throat - cleft palate, dental caries, tonsillar size, strawberry tongue - EXAMINE LAST
8. Neck - lymphadenopathy, webbing (Turner syndrome), thyroid
9. Chest/Lungs - chest shape (Harrison's sulcus), air entry, wheeze, crepitations
10. Cardiovascular - apex beat, murmurs (grade, timing, location, radiation)
11. Abdomen - umbilical hernia (common <2 years, usually self-resolving), hepatosplenomegaly, masses - use light palpation for spleen
12. Genitalia - Males: circumcision, hypospadias, undescended testes (examine BEFORE child is chilled; start above inguinal canal working downward), hydrocele; Females: imperforate hymen, discharge, clitoral size; Pubertal changes (Tanner staging)
13. Extremities - bowlegs (normal in infancy), knock-knees (normal after age 2), flat feet (normal first 2 years), extra digits, clubbing, joint swelling
14. Spine - scoliosis (Adam's forward bend test), spina bifida, pilonidal dimple, kyphosis
15. Hips - Barlow/Ortolani in neonates
16. Neurological - tone, power, reflexes, primitive reflexes (in infants), cranial nerves, cerebellar signs

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PART 3: DETAILED VIVA QUESTIONS FOR PRACTICAL EXAMINATION

Section A: General Principles

Surveillance is informal and ongoing at every visit - it includes clinical observation, eliciting parental concerns, and direct observation of the child. Screening is formal and uses a validated, standardized scored tool at specific ages to identify children at risk. Surveillance does not replace screening; both are needed. (Harriet Lane Handbook)

Formal standardized screening at 9 months, 18 months, and 30 months (or 24 months if 30-month visit is not feasible). ASD-specific screening is done at 18 and 24 months using M-CHAT-R/F.

Approach slowly, do NOT rush to touch; observe during history taking; perform cardiac/respiratory exam first while the child is quiet; examine throat and ears LAST as they cause the most distress; use the parent's lap for children 8 months to 3 years.

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Section B: Developmental Milestones

Approximately 12 months (1 year).

By 24 months. Absence of 2-word phrases by 24 months is a developmental RED FLAG requiring immediate evaluation. A child should also have a vocabulary of >50 words by 24 months.

Domains: (1) Personal-Social, (2) Fine Motor-Adaptive, (3) Language, (4) Gross Motor. Scores: Normal (no delays, maximum 1 caution), Suspect (2+ cautions OR 1 delay), Untestable (refuses items).

Object permanence (looking for an object after it falls out of sight) is a 9-month milestone. Failure to achieve it at 9 months combined with other delays is concerning. Isolated delay in one domain requires close surveillance with re-assessment.

Regression - loss of previously acquired skills - is ALWAYS a red flag and mandates immediate investigation regardless of age.

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Section C: Neonatal Screening

The Guthrie bacterial inhibition assay detects elevated blood phenylalanine. It screens for Phenylketonuria (PKU). Blood is collected by heel-prick at 6-10 days on thick absorbent filter paper. PKU is caused by PAH (phenylalanine hydroxylase) enzyme deficiency, is autosomal recessive, incidence 1:10,000-20,000, and causes mental retardation if untreated. Treatment is a low phenylalanine diet.

Congenital hypothyroidism. It is screened by measuring TSH or T4 by radioimmunoassay. If untreated, it causes irreversible severe mental retardation. Treatment must begin within the first 1-2 months of life.

By Barlow test (adduction - provokes dislocation) and Ortolani test (abduction - reduces dislocation). A click or clunk = positive. Screening is done at 6-14 days after birth, then monthly until 4 months. Early diagnosis allows treatment before standing age, avoiding complex surgical interventions later.

10-15 mL cord blood is saved in the refrigerator for blood typing, Coombs' test, and any other tests needed if the newborn develops jaundice or other problems.

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Section D: Vision and Hearing Screening

By 5-6 years of age. At 6 months it is 20/200; at 1 year 20/40.

Otoacoustic Emissions (OAE) as the first-line screen; if failed, Automated Auditory Brainstem Response (AABR). Done before hospital discharge. Target: detect hearing loss before 3 months and begin intervention before 6 months.

Use picture/Allen cards or a Snellen chart with pictures (E chart). Look for visual acuity <20/50, difference of 2+ lines between eyes (suggests amblyopia), or failure to cooperate suggesting a visual problem. Refer to ophthalmology.

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Section E: ASD Screening

Modified Checklist for Autism in Toddlers - Revised with Follow-up. Parent-completed 20-item questionnaire for ages 16-30 months. Score 0-2 = low risk; 3-7 = medium risk (proceed to structured follow-up interview); 8-20 = high risk (immediate referral). It is free and available in 50+ languages.

(1) Lack of joint attention (not pointing to show objects, not sharing interest), (2) diminished or absent eye contact, (3) no imitation of facial expressions or gestures, (4) lack of response to name, (5) echolalia, (6) repetitive motor behaviors (hand-flapping, spinning), (7) unusual sensory responses.

Formally at 18 months and 24 months using M-CHAT-R/F, per AAP guidelines.

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Section F: Growth and Nutrition

Failure to thrive (FTT) is weight-for-age persistently below the 3rd percentile OR crossing downward across 2 major percentile lines on the growth chart. Assess by plotting serial measurements on a growth chart, calculating weight-for-height z-score, taking dietary history, and investigating for organic causes (if weight falls, then height, then head circumference - suggests organic; if all fall proportionately - suggests constitutional or nutritional).

This is a red flag for progressive macrocephaly. Suspect hydrocephalus, megalencephaly, or subdural collection. Urgent head imaging (ultrasound if fontanelle is open; MRI/CT if closed) is indicated.

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Section G: Cardiovascular Screening

A 12-element history and physical examination. No routine ECG is required unless there is clinical suspicion of cardiac disease. Key history elements: exertional chest pain, syncope, unexplained fatigue, prior murmur, hypertension; family history of premature sudden cardiac death (<50 years), Marfan syndrome, cardiomyopathy.

At age 3 years at every well-child visit. Before age 3, measure blood pressure if there are specific risk factors (prematurity, renal disease, cardiac disease, recurrent UTIs).

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Section H: Examination Techniques

These are the most distressing parts of the examination. If done early, the child becomes upset and crying, making it impossible to properly auscultate the heart and lungs or assess tone. By leaving them last, you preserve the quality of the rest of the examination.

Examine BEFORE the child is fully undressed or has become cold (to prevent cremasteric reflex). Start palpation ABOVE the inguinal canal and work downward. Can also try with the child sitting holding knees on chest (increases intra-abdominal pressure which may push testes into scrotum). In obese children, push back the fat pad - the penis is often normal size. Examination in a warm bath may also help relax the cremasteric reflex.

Anterior fontanelle: Normally closes 12-18 months; bulging = raised ICP (meningitis, hydrocephalus); sunken = dehydration; delayed closure = hypothyroidism, rickets, hydrocephalus. Posterior fontanelle: Closes 2-3 months; early closure = craniosynostosis.

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Section I: Immunization (Screening Context)

Typically at birth (BCG, Hep B), 6 weeks/2 months (DPT, IPV/OPV, Hib, Hep B, PCV, Rotavirus), 10 weeks/4 months (DPT, IPV/OPV, Hib, PCV, Rotavirus), 14 weeks/6 months (DPT, IPV/OPV, Hib, PCV, Rotavirus, Hep B), 9 months (Measles/MMR), 12 months (second MMR in some schedules). Exact schedule varies by country/national program.

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Section J: Screening Tools Summary Table

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QUICK EXAM MNEMONIC AIDS

• Home environment
• Education/Employment
• Activities/Peers
• Drugs/Alcohol
• Sexuality
• Suicide/Mental health

• Appearance (color)
• Pulse (heart rate)
• Grimace (reflex irritability)
• Activity (muscle tone)
• Respiration

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CBR PRACTICAL EXAM: PEDIATRIC SCREENING FOR HIGH-RISK BABIES

Complete Step-by-Step Guide with Viva Questions

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WHAT IS CBR? (Quick Context for Viva)

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PART 1: IDENTIFICATION OF A HIGH-RISK BABY

Before you touch the baby - IDENTIFY if the baby is HIGH RISK

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CRITERIA FOR IDENTIFYING "AT-RISK" INFANTS

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ADDITIONAL HIGH-RISK PERINATAL/NEONATAL CRITERIA (Modern Evidence)

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PART 2: STEP-BY-STEP PEDIATRIC SCREENING PROCEDURE

PRE-EXAMINATION PREPARATION

"I will first introduce myself to the parent/caregiver, obtain a brief history, and observe the baby before proceeding to examination."

• Wash with warm water (important - cold hands startle the baby and trigger crying)

• Watch the baby's spontaneous activity during history taking
• Note: posture, movement, alertness, colour, breathing pattern, facial expressions

1. Antenatal history - Maternal illness (HTN, DM, thyroid, TORCH), drug/alcohol/tobacco use, prenatal care, ultrasound findings
2. Birth history - Gestational age, place of delivery, mode of delivery, birth weight, cry at birth (immediate vs delayed)
3. Neonatal history - NICU admission, jaundice, seizures, feeding difficulties, oxygen requirement
4. Current concerns - Parent's concerns about development, vision, hearing, feeding
5. Developmental history - Milestones achieved (ask specifically for each domain)
6. Nutritional history - Breastfed or formula? Weaning started? Current diet?
7. Immunization history - Up to date?
8. Family history - Developmental disabilities, genetic conditions, consanguinity
9. Social history - Who is the primary caregiver? Mother's occupation? Socioeconomic status?

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STEP 4: ANTHROPOMETRY (Measurements FIRST)

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STEP 5: NUTRITIONAL STATUS ASSESSMENT

• Oedema (kwashiorkor)
• Wasting of muscles (marasmus)
• Skin changes (flaky paint dermatosis)
• Hair changes (flag sign, easily pluckable)
• Hepatomegaly (kwashiorkor)

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STEP 6: VITAL SIGNS

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STEP 7: SYSTEMATIC PHYSICAL EXAMINATION (Head to Toe)

7A. GENERAL APPEARANCE

• Conscious, alert vs lethargic
• Dysmorphic features (Down syndrome, FAS, chromosomal abnormalities)
• Nutritional state
• Skin color: jaundice, pallor, cyanosis, plethora

7B. SKIN

• Birthmarks: Mongolian spots (normal - blue-grey sacral), port-wine stain (Sturge-Weber), cafe-au-lait spots (NF1 if >6 and >0.5 cm), ash-leaf spots (Tuberous sclerosis)
• Rashes, petechiae
• Subcutaneous fat - pinch skin folds for turgor

7C. HEAD

• Shape: Plagiocephaly, dolichocephaly, craniosynostosis
• Fontanelles:
  • Anterior fontanelle (diamond-shaped): open until 12-18 months
    • Bulging = raised ICP (meningitis, hydrocephalus)
    • Sunken = dehydration
    • Tense + pulsatile = normal
    • Delayed closure = hypothyroidism, rickets, Down syndrome, hydrocephalus
  • Posterior fontanelle (triangular): closes by 6-8 weeks
    • Early closure = craniosynostosis
• Sutures: feel for overriding (normal after birth), craniotabes

7D. EYES

• Red reflex: use ophthalmoscope - absence = cataract, retinoblastoma (URGENT)
• Corneal light reflex (Hirschberg): light should fall symmetrically - asymmetry = squint/strabismus
• Cover-uncover test: for latent squint
• Eye movements: hold a toy and track in all directions
• Nystagmus, sunset sign (raised ICP/hydrocephalus), coloboma, epicanthic folds (Down syndrome)
• Vision: follows face/bright object from newborn period; fixes and follows by 6 weeks

7E. EARS

• Low-set ears (rule of eye-corner-ear alignment) - suggests Down syndrome, renal anomalies
• Pre-auricular tags, sinuses
• Otoscopy: TM colour, light reflex, bony landmarks, effusion
• Hearing assessment: (see dedicated section below)

7F. NOSE

• Nasal flaring (respiratory distress)
• Choanal atresia (bilateral = emergency - cannot pass NG tube through nose)
• Discharge

7G. MOUTH AND THROAT (EXAMINE LAST)

• Cleft lip/palate
• High arched palate (Down syndrome, Turner syndrome)
• Macroglossia (hypothyroidism, Down syndrome, Beckwith-Wiedemann)
• Dental caries, oral hygiene
• Tonsils size (Grade I-IV)
• Strawberry tongue (Kawasaki, scarlet fever)
• Koplik's spots (measles)

7H. NECK

• Lymphadenopathy - size, consistency, tenderness
• Webbed neck (Turner syndrome, Noonan syndrome)
• Thyroid - size, nodules
• Neck stiffness (meningism)
• Short neck (Klippel-Feil)

7I. CHEST AND LUNGS

• Shape: Harrison's sulcus (chronic respiratory disease/rickets), barrel chest, pectus excavatum/carinatum
• Air entry: bilateral, equal
• Added sounds: wheeze, crepitations, stridor
• Tachypnoea, grunting, intercostal/subcostal recessions (respiratory distress in neonates)

7J. CARDIOVASCULAR

• Apex beat position (normal: 4th intercostal space, midclavicular line until 7 years)
• Heart sounds: murmurs - grade, timing (systolic/diastolic), location, radiation
• Peripheral pulses: brachial (infants), radial/femoral simultaneously (radio-femoral delay = coarctation)
• Capillary refill time (normal <2 seconds)

7K. ABDOMEN

• Distension, visible peristalsis
• Umbilicus: umbilical hernia (common <2 years; usually self-resolving), discharge, granuloma
• Liver: normally 1-2 cm below RCM in infants - measure in cm below costal margin
• Spleen: use LIGHT palpation; note size in cm below LCM
• Kidneys: bimanual palpation (enlarged = hydronephrosis, Wilms tumour)
• Hernias: inguinal, femoral - check both groins

7L. GENITALIA

• Males: circumcision status, meatal position (hypospadias/epispadias), testicular descent
  • Undescended testes: start palpation ABOVE inguinal canal working downward; examine BEFORE child gets cold
• Females: vaginal discharge, labial adhesions, imperforate hymen
• Both: note Tanner staging (pubertal assessment)

7M. EXTREMITIES

• Bowlegs (genu varum - normal <2 years)
• Knock-knees (genu valgum - normal 2-7 years)
• Flat feet (normal <2 years)
• Joint swelling, warmth, tenderness
• Clubbing (cyanotic CHD, chronic lung disease)
• Oedema
• Extra digits (polydactyly), fused digits (syndactyly)
• Simian crease (Down syndrome)

7N. SPINE AND BACK

• Scoliosis: Adam's forward-bend test
• Kyphosis, lordosis
• Spina bifida, pilonidal sinus, sacral dimple, tuft of hair
• Mongolian spots (sacral area - note do NOT confuse with bruising)

7O. HIPS (Neonates and Infants)

• Barlow test: hip adducted, pressure applied - feels/hears clunk = hip dislocates
• Ortolani test: hip abducted, gentle lift - feels/hears clunk = hip reduces
• Positive = developmental dysplasia of hip (DDH)
• Done at 6-14 days of life then monthly until 4 months
• Asymmetric skin folds, limited abduction = suspect DDH in older babies

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STEP 8: NEUROLOGICAL EXAMINATION (CRITICAL FOR HIGH-RISK BABY)

8A. Tone Assessment

• Passive tone: feel resistance to passive movement
  • Hypotonia (floppy baby): Down syndrome, hypothyroidism, hypoxic-ischaemic injury, spinal muscular atrophy
  • Hypertonia (stiff baby): cerebral palsy, HIE, meningitis
• Ventral suspension: hold baby prone in air - normal baby extends trunk, keeps head in line
• Vertical suspension: hold baby upright under axilla - normal baby bears weight; scissoring = CP
• Horizontal suspension: hold baby prone on palm - normal head/trunk in line
• Head lag test: pull baby from supine to sitting holding hands - note head control

8B. Primitive Reflexes (CRITICAL for Neonates and High-Risk Babies)

Key Viva Point: Persistence of primitive reflexes beyond their normal disappearance age is a RED FLAG for neurological abnormality (cerebral palsy, brain injury).

8C. Deep Tendon Reflexes

• Biceps (C5-6), Triceps (C6-7), Knee (L3-4), Ankle (S1-2)
• Clonus: >5 beats = upper motor neuron lesion

8D. Cranial Nerve Assessment (Simplified for Infants)

• CN II/III: Visual tracking, pupillary reflexes
• CN III/IV/VI: Eye movements, squint
• CN V: Rooting, sucking, facial sensation
• CN VII: Facial symmetry (smile, cry)
• CN VIII: Response to sound/voice
• CN IX/X: Swallowing, gag reflex
• CN XII: Tongue movements

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STEP 9: DEVELOPMENTAL SCREENING (USE CORRECTED AGE FOR PRETERM)

CRITICAL RULE: For premature babies, ALWAYS use CORRECTED AGE for developmental assessment, not chronological age. Formula: Corrected Age = Chronological Age - (40 weeks - Gestational Age at birth) Example: A 6-month-old born at 32 weeks → Corrected age = 6 months - 2 months = 4 months

Assess All 4 Domains:

• Observe: Can baby hold head up? Sit? Stand? Walk? Run?
• Test: Pull to sit (head lag), ventral suspension, standing with support

• Observe: Reaching, grasping, transferring objects, pincer grasp
• Test: Dangle a brightly coloured toy, observe tracking and reaching

• Observe: Cooing, babbling, words, sentences
• Ask parent about response to voice, name recognition

• Observe: Social smile, eye contact, stranger anxiety, imitation
• Ask about interaction with caregiver

Developmental Milestones Quick Reference:

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STEP 10: VISION SCREENING

• Fix/follow face: 4-6 weeks
• Smooth tracking: 3 months
• 20/200 at 6 months
• 20/40 at 1 year
• 20/20 by 5-6 years

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STEP 11: HEARING SCREENING

• NICU stay >5 days
• Aminoglycoside use
• Neonatal meningitis/encephalitis
• Severe jaundice (exchange transfusion)
• Family history of childhood hearing loss
• Craniofacial anomalies

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STEP 12: NEONATAL/METABOLIC SCREENING (Heel-Prick Panel)

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STEP 13: IMMUNIZATION STATUS CHECK

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STEP 14: COMPLETE THE SCREENING WITH ASSESSMENT AND REFERRAL

1. Is this a HIGH-RISK baby? - YES/NO with reasons
2. Is development NORMAL, SUSPECT, or DELAYED? - State which domains
3. Red flags identified? - List them
4. What is your management plan?

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PART 3: VIVA QUESTIONS WITH ANSWERS (CBR PRACTICAL EXAM)

GROUP A: High-Risk Baby Identification

(1) Birth weight <2.5 kg, (2) Twins, (3) Birth order 5+, (4) Artificial feeding, (5) Weight <70% expected (Grade II/III malnutrition), (6) Failure to gain weight in 3 successive months, (7) PEM or diarrhoea, (8) Working mother/single parent.

LBW = birth weight <2.5 kg (up to and including 2499 g), measured preferably within the first hour of life. Two types: (1) Preterm - born before 37 completed weeks; (2) Small for Gestational Age (SGA)/IUGR - fetal growth retardation but term gestation. In India, majority of LBW is due to IUGR, not prematurity.

Birth weight is the single most important determinant of chances of survival, healthy growth and development. LBW babies have higher rates of perinatal/neonatal mortality, developmental delay, cerebral palsy, feeding difficulties, respiratory problems, and long-term cognitive impairment.

Hypoxic Ischaemic Encephalopathy (HIE) results from perinatal asphyxia - oxygen deprivation to the brain around birth. It causes neurotoxicity affecting motor, cognitive and language development. Sequelae include cerebral palsy, epilepsy, intellectual disability, and vision/hearing impairment. These babies require intensive developmental follow-up.

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GROUP B: Examination Technique

(1) Moro reflex - drop head slightly, arms abduct then adduct - disappears 4-6 months. (2) Rooting - stroke corner of mouth, baby turns toward stimulus - disappears 3-4 months. (3) Palmar grasp - place finger in palm, fingers curl - disappears 3-4 months. (4) ATNR - turn head to side, ipsilateral arm extends - disappears 4-6 months. (5) Stepping reflex - hold upright, sole touches surface, stepping movements - disappears 2-3 months.

Persistence beyond the normal disappearance age indicates upper motor neuron pathology, most commonly cerebral palsy or other brain injury. For example, persistent ATNR after 6 months, persistent Moro after 6 months, or persistent palmar grasp after 4 months should raise concern.

Assess tone by: (1) Passive tone - feel resistance to passive limb movement. (2) Ventral suspension - hold prone, see if trunk/head stay extended. (3) Head lag - pull to sitting, note how much head lags. Hypotonia (floppy baby) suggests Down syndrome, congenital hypothyroidism, spinal muscular atrophy, hypoxic-ischaemic injury, or metabolic disorders.

The parachute reflex is elicited by holding the baby horizontally and tilting suddenly head-downward - the arms extend forward as if to break a fall. It appears at 6-9 months and persists permanently. Unlike other primitive reflexes, it should APPEAR - its absence or asymmetry after 9 months is a red flag for cerebral palsy.

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GROUP C: Corrected Age (KEY High-Risk Baby Concept)

Corrected age = Chronological age minus the number of weeks premature. Formula: Corrected age = Chronological age - (40 weeks - gestational age at birth) Example: A baby born at 28 weeks who is now 8 months old has a corrected age of 8 months - (40-28) weeks = 8 months - 3 months = 5 months. You assess developmental milestones against a 5-month-old, not an 8-month-old.

Use corrected age up to 2 years (24 months corrected age) for gross motor and language. For very preterm babies (<28 weeks), some clinicians use correction until 3 years. After 2-3 years, the developmental gap usually narrows enough that correction is no longer required.

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GROUP D: Neonatal Screening

Scored at 1 minute and 5 minutes. Five components, each 0-2:

• A ppearance (color): blue/pale = 0; blue extremities, pink body = 1; completely pink = 2
• P ulse: absent = 0; <100 = 1; ≥100 = 2
• G rimace (reflex irritability): no response = 0; grimace = 1; cough/sneeze/cry = 2
• A ctivity (muscle tone): limp = 0; some flexion = 1; active motion = 2
• R espiration: absent = 0; irregular/slow = 1; strong cry = 2 Score 7-10 = normal; <7 at 5 minutes = resuscitation continues.

The Guthrie bacterial inhibition assay detects elevated blood phenylalanine. It is done by heel-prick at 6-10 days of life (not earlier, because phenylalanine builds up after protein feeding starts). Blood is collected on thick absorbent filter paper in 3-4 drops. It screens for PKU (Phenylketonuria - PAH deficiency, autosomal recessive, incidence 1:10,000-20,000). Same filter paper card tests for galactosaemia and MSUD.

Two tests: Barlow test (provocation) - flex hip 90°, adduct and push posteriorly - clunk = hip dislocates Ortolani test (reduction) - flex hip 90°, abduct and lift anteriorly - clunk = hip reduces Done at 6-14 days after birth, then monthly until 4 months. Other signs in older infants: asymmetric inguinal folds, limited abduction, Galeazzi sign (knee height difference). Early diagnosis = Pavlik harness; delayed = surgery.

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GROUP E: Developmental Red Flags

(1) Any regression/loss of previously acquired skills - at ANY age (2) No social smile by 8 weeks (3) Not fixing and following by 6 weeks (4) No words by 12 months (5) No 2-word phrases by 24 months (6) Unable to sit unsupported by 12 months (7) Not walking by 18 months (males) or 24 months (females) (8) Head circumference crossing 2 percentile lines up or down (9) Persistent asymmetry of movement/tone (10) Absence of parachute reflex by 9 months

No - not yet. Calculate corrected age: 6 months - (40-30 weeks) = 6 months - 2.5 months = approximately 3.5 months corrected age. Sitting unsupported is a 6-9 month milestone. At 3.5 months corrected age, the baby should be showing head control and beginning to push up on forearms - check for those. It becomes a red flag only if sitting is not achieved by 12 months corrected age.

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GROUP F: CBR-Specific Questions

In CBR, the community worker identifies high-risk babies, performs basic developmental surveillance using standardized tools, educates parents about stimulation activities, refers to appropriate specialists (physiotherapist, OT, speech therapist, ophthalmologist, audiologist), facilitates access to services, provides home-based follow-up, advocates for disability inclusion in schools, and monitors progress.

CBR means delivering rehabilitation/habilitation services at the community level rather than only at institutional level. For a high-risk baby, it means early identification, early intervention, parent-guided developmental stimulation at home, integration into community resources (inclusive education), and multidisciplinary coordination - all without requiring the family to travel to a distant tertiary centre.

This child has multiple red flags suggesting cerebral palsy or global developmental delay:

1. Urgent referral to paediatric neurologist for diagnosis
2. Referral to physiotherapist (for hypotonia, motor delay)
3. Referral to speech and language therapist (for no words/feeding)
4. Referral to occupational therapist (for fisting, fine motor)
5. Ophthalmology and audiology screening
6. Parent/caregiver training in home stimulation
7. Social worker for financial aid and support group access
8. Schedule CBR follow-up at 1 month to assess progress

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QUICK EXAM MNEMONICS

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DEMONSTRATE: PEDIATRIC SCREENING OF A HIGH-RISK INFANT

Exact Step-by-Step — What to DO, SAY, and LOOK FOR

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How to use this guide: The text in "quotes" is what you SAY OUT LOUD to the examiner. The rest describes what you physically DO. This is your script for the practical.

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PHASE 1: BEFORE YOU TOUCH THE BABY (2 minutes)

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STEP 1 - Introduction and Consent

"Good morning. My name is [your name]. I am a student/therapist. I would like to perform a routine screening examination of your baby to check on their growth, development, and overall health. Do I have your permission to proceed?"

• Confirm baby's name and age
• Ask mother to sit comfortably with baby on her lap OR place baby on examination table if >4 months and cooperative

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STEP 2 - Wash Hands

"I am washing my hands with warm water before I begin. This is to prevent infection and also so my hands are warm before I touch the baby."

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STEP 3 - Observe First (Before Touching)

"Before I touch the baby, I am observing general appearance first."

"I am noting the baby's level of alertness - is the baby alert, responsive, or lethargic? I am observing the spontaneous posture and movement - a normal infant lies with limbs flexed. I am noting the skin color - looking for pallor, jaundice, or cyanosis. I am observing breathing pattern - are there any signs of respiratory distress such as fast breathing, grunting, or chest recessions? I am also looking for any obvious dysmorphic features."

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STEP 4 - Focused History (Narrate the key questions)

"Before the physical examination, I will take a brief focused history to identify high-risk factors."

"Based on the history, I am identifying the following high-risk factors in this baby: [list what you found - e.g., birth weight was 2.1 kg (LBW), preterm at 34 weeks, NICU stay for 10 days, mother is working]. This baby qualifies as a HIGH-RISK infant and I will now proceed with a comprehensive screening."

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PHASE 2: MEASUREMENTS (Anthropometry)

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STEP 5 - Take All Four Measurements

"I will now take anthropometric measurements and plot them on the WHO growth chart."

5A. Weight

• Normal: birth weight ~3.0-3.5 kg; regains birthweight by day 10-14
• High-risk flag: weight <2.5 kg (LBW)

5B. Length/Height

5C. Head Circumference

• High-risk flags: crossing 2 major centile lines upward (hydrocephalus) or downward (microcephaly)

5D. Mid-Upper Arm Circumference (MUAC) - Important in CBR

"I have plotted all measurements on the WHO growth chart. The baby's weight is at the [X]th centile, length at [X]th centile, and head circumference at [X]th centile. [State if any are abnormal or crossing centile lines.] This suggests [normal growth / failure to thrive / stunting / microcephaly]."

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PHASE 3: VITAL SIGNS

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STEP 6 - Check Vital Signs

Respiratory Rate first (baby must be QUIET)

Heart Rate

Temperature

Blood Pressure (if >3 years or if specifically indicated in high-risk)

SpO2 (if equipment available)

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PHASE 4: PHYSICAL EXAMINATION (Head to Toe)

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GOLDEN RULE - Say this to the examiner:

"I will follow the rule: start with the LEAST DISTRESSING parts first. I will do cardiac and respiratory examination first while the baby is quiet, and leave the mouth and ears examination for LAST as they cause the most crying. I will use the mother's lap for an infant under 3 years."

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STEP 7A - General Appearance (already done by observation)

"On general inspection: the baby appears [alert/lethargic], [well-nourished/wasted/oedematous], [pink/pale/jaundiced/cyanosed]. Posture is [normal flexed position / hypotonic / hypertonic]. I note [presence/absence of] dysmorphic features."

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STEP 7B - Skin

"I am examining the skin. I am looking for: jaundice (best seen in sclera and gums), pallor (look at conjunctivae and palms), cyanosis (central vs peripheral), bruising, petechiae, and birthmarks."

"Specifically in a high-risk baby I am looking for neurocutaneous markers: cafe-au-lait spots (>6, >0.5 cm = Neurofibromatosis), ash-leaf hypopigmented spots (Tuberous sclerosis), port-wine stain over face (Sturge-Weber syndrome), and Mongolian spots over sacrum (normal blue-grey pigmentation - do NOT confuse with bruising)."

"Skin turgor: I will gently pinch the abdominal skin - it should spring back immediately. Tenting = dehydration."

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STEP 7C - HEAD

"I am examining the head. I note the shape - looking for plagiocephaly, brachycephaly, or any asymmetry."

"I am palpating the ANTERIOR FONTANELLE - it is normally diamond-shaped, soft, and flat. It closes between 12-18 months. A BULGING fontanelle = raised intracranial pressure (meningitis, hydrocephalus). A SUNKEN fontanelle = dehydration. DELAYED closure = hypothyroidism, rickets, Down syndrome."

"I am palpating the POSTERIOR FONTANELLE - normally closes by 6-8 weeks. Early closure = craniosynostosis."

"I am feeling the sutures for overriding (normal after delivery) and for premature fusion (craniosynostosis)."

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STEP 7D - EYES

"I am examining the eyes. First I check the FUNDAL RED REFLEX - I shine the ophthalmoscope light into the pupil from 30 cm. A bright red-orange glow = normal. A white reflex (leukocoria) = URGENT referral - suggests cataract, retinoblastoma, or retinal detachment."

"I am checking the CORNEAL LIGHT REFLEX (Hirschberg test) - I shine a torch from 30 cm directly at both eyes. Light should fall symmetrically on both corneas. Asymmetry = squint/strabismus."

"I am checking eye spacing - epicanthic folds and upward slanting eyes suggest Down syndrome."

"I am checking the baby TRACKS a moving object/face - this should be present from 4-6 weeks of age."

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STEP 7E - CARDIOVASCULAR (Do while baby is quiet)

"I am examining the cardiovascular system. I am inspecting for visible cardiac impulse or chest asymmetry."

"I am palpating the APEX BEAT - normally at 4th intercostal space, midclavicular line in infants under 7 years."

"I am auscultating the 4 valve areas with the diaphragm, then bell of my stethoscope - I am listening for S1, S2, and any murmurs. A systolic murmur may indicate a VSD or other congenital heart disease, which is more common in high-risk infants."

"I am palpating the femoral and brachial pulses simultaneously. A RADIO-FEMORAL DELAY or absent femoral pulse = coarctation of the aorta."

"I am checking CAPILLARY REFILL TIME by pressing the sternum for 5 seconds and releasing. Normal CRT = less than 2 seconds."

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STEP 7F - RESPIRATORY

"I am examining the chest and lungs. I inspect the chest shape - Harrison's sulcus (horizontal groove at lower rib margin) suggests chronic respiratory disease or rickets. I look for SIGNS OF RESPIRATORY DISTRESS: tachypnoea, nasal flaring, intercostal retractions, subcostal recessions, grunting, and use of accessory muscles."

"I am auscultating both lung fields symmetrically - top to bottom, comparing side to side. I am listening for equal air entry, and any added sounds: wheeze, crepitations, or stridor."

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STEP 7G - ABDOMEN

"I am examining the abdomen. I inspect first: I note any distension, visible peristalsis, and I inspect the UMBILICUS for hernia (common <2 years, usually self-resolving), discharge, or infection."

"I am palpating LIGHTLY - I use flat of the hand, warm, watching the baby's face for pain. I palpate for the LIVER - normally felt 1-2 cm below the right costal margin in infants. Hepatomegaly in a high-risk baby suggests congenital infection (TORCH), metabolic disorder, or heart failure."

"I am palpating for the SPLEEN - I use LIGHT palpation as it is fragile. I start from the right iliac fossa moving up to the left costal margin."

"I am checking for any masses, and palpating both groins for inguinal hernias."

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STEP 7H - GENITALIA

"I am examining the genitalia with respect for modesty. In a male baby I am checking: whether the baby is circumcised, the position of the urethral meatus (hypospadias if on underside, epispadias if on top), and whether BOTH testes are palpable in the scrotum."

"For undescended testes, I start palpation ABOVE the inguinal canal and work DOWNWARD to avoid pushing the testis further up. I must examine BEFORE the baby becomes cold, as the cremasteric reflex will retract the testis."

"In a female baby I am checking for vaginal discharge, labial adhesions, and clitoral size."

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STEP 7I - SPINE AND BACK

"I am turning the baby prone to inspect the spine. I am looking along the spine for scoliosis, kyphosis, or lordosis. I am inspecting the lower back for a sacral dimple, pilonidal sinus, tuft of hair, or any midline defect that could indicate spina bifida occulta."

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STEP 7J - HIPS (Critical in Neonates and Young Infants)

"I am screening for Developmental Dysplasia of the Hip (DDH). This is done at 6-14 days of life and then monthly until 4 months."

"BARLOW TEST (provocation): I flex the hip to 90°, adduct the thigh and apply gentle downward posterior pressure. A CLUNK felt = hip dislocates = POSITIVE."

"ORTOLANI TEST (reduction): I flex the hip to 90°, abduct the thigh fully while lifting the greater trochanter upward. A CLUNK felt = hip reduces back in = POSITIVE."

"In an older infant I look for: asymmetric skin folds, limited hip abduction (<60°), leg length discrepancy (Galeazzi sign), and limping in a walking child."

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STEP 7K - EXTREMITIES

"I am examining all four limbs. I look for symmetry of movement - asymmetric spontaneous movement is a RED FLAG for hemiplegia or birth injury. I check for extra digits (polydactyly), fused digits, simian crease (Down syndrome), and clubbing. I check joint swelling, warmth, or tenderness. I note bowlegs (normal <2 years) and knock-knees (normal 2-7 years)."

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PHASE 5: NEUROLOGICAL EXAMINATION (Most Important for High-Risk Baby)

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STEP 8 - Tone, Reflexes, and Posture

"I will now perform a detailed neurological examination, which is especially important in this high-risk baby."

8A - Muscle Tone

"I am assessing PASSIVE TONE by moving limbs through their full range - feeling for resistance. [Normal / Hypotonic / Hypertonic]."

"HEAD LAG TEST: I gently pull the baby from supine to sitting by both wrists. In a normal 3-month-old, the head should be held in line with the trunk. Marked head lag after 4 months = hypotonia or neurological problem."

"VENTRAL SUSPENSION: I hold the baby horizontally face down on my palm. A normal baby holds head in line with the trunk and shows a straight back. A FLOPPY baby droops like an inverted U = hypotonia."

"VERTICAL SUSPENSION: I hold baby upright under the axilla. A normal baby bears some weight through legs. If the legs SCISSOR (cross) = hypertonia - suspect cerebral palsy."

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8B - Primitive Reflexes (NARRATE EACH ONE)

"I will now test primitive reflexes. Persistence beyond the normal disappearance age is a red flag for cerebral palsy or brain injury."

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8C - Deep Tendon Reflexes

"I am testing deep tendon reflexes - knee jerk (L3-4) and ankle jerk (S1-2). Normal response = brisk. CLONUS (>5 beats) = upper motor neuron lesion."

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PHASE 6: DEVELOPMENTAL SCREENING

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STEP 9 - Calculate Corrected Age First (CRITICAL)

"Before I assess developmental milestones, I must calculate the CORRECTED AGE because this is a preterm/high-risk baby."

"Corrected age = Chronological age minus weeks of prematurity. For example: if this baby is 6 months old and was born at 32 weeks, the corrected age is 6 months minus 2 months = 4 months. I will assess milestones against a 4-month-old, not a 6-month-old. I use corrected age until 2 years."

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STEP 10 - Assess All 4 Developmental Domains

"I am assessing the 4 domains of development systematically."

DOMAIN 1: GROSS MOTOR

"I observe whether the baby can [hold head up / sit / stand / walk] appropriate for corrected age. I perform pull-to-sit to assess head control."

DOMAIN 2: FINE MOTOR

"I dangle a bright-colored toy at midline within reach. I observe for: visual fixation, reaching, grasping, and transferring between hands."

DOMAIN 3: LANGUAGE

"I am assessing language. I call the baby's name - does the baby turn? I make a sound out of the visual field - does the baby turn toward it? I ask the mother: is the baby cooing, babbling, saying words?"

DOMAIN 4: PERSONAL-SOCIAL

"I am observing social development: eye contact, social smile (expected by 6-8 weeks), response to familiar faces, and separation anxiety (normal from 8-9 months)."

"Based on developmental assessment: [this baby is achieving milestones appropriate for corrected age of X months] OR [this baby is showing a delay in the [gross motor/fine motor/language/social] domain - which is a red flag requiring further evaluation and referral]."

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PHASE 7: SPECIAL SCREENINGS

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STEP 11 - Vision Screening

"I am performing vision screening. I check the RED REFLEX bilaterally with the ophthalmoscope. I check whether the baby FIXES on a face and FOLLOWS a moving object. In a baby over 3 months, I perform the cover-uncover test to check for squint. White reflex = urgent ophthalmology referral."

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STEP 12 - Hearing Screening

"I am performing a bedside hearing screen. I make a sharp sound (clap, rattle, or ring a small bell) at ear level, 30 cm from the ear, OUT OF THE BABY'S VISUAL FIELD. I observe for blinking, startle, quieting, or turning toward the sound. For a high-risk baby I specifically ask whether newborn OAE (otoacoustic emission) test was done before hospital discharge."

"This baby is at high risk for hearing loss because: [NICU stay >5 days / aminoglycoside use / neonatal meningitis / severe jaundice / family history]. Formal audiology referral is indicated if not already done."

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STEP 13 - Nutritional Assessment

"I am assessing nutritional status. Based on the weight-for-age: [normal / Grade I / Grade II at-risk / Grade III high-risk malnutrition]. I am looking for clinical signs of malnutrition: bilateral oedema (kwashiorkor), severe wasting (marasmus), pale/sparse hair, and hepatomegaly."

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STEP 14 - Immunization Check

"I am checking the immunization card. For this [age]-month-old baby, the following vaccines should have been given: [list expected vaccines]. The baby [is/is not] up to date. [If missed vaccines: I will arrange catch-up vaccination today.]"

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PHASE 8: EXAMINATION OF MOUTH AND EARS (LAST)

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STEP 15 - Mouth/Throat (ALWAYS LAST)

"I am now examining the mouth - I leave this for last as it is the most distressing part. I use a torch and tongue depressor. I am checking for cleft palate (must visualize the FULL palate including uvula - palpation is not enough), tongue tie (ankyloglossia), dental caries, and tonsillar enlargement."

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STEP 16 - Ears (LAST)

"I am performing otoscopy. I am straightening the ear canal by pulling the pinna downward and backward (in infants). I inspect: the ear canal for discharge or foreign body, and the tympanic membrane for color (normally pearly grey), light reflex (cone of light at 5 o'clock right, 7 o'clock left), bony landmarks (handle of malleus visible), and any perforation or fluid behind the drum."

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PHASE 9: SUMMARIZE YOUR FINDINGS

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STEP 17 - Present to Examiner

"I have completed the pediatric screening of this high-risk infant. Let me summarize my findings:"

1. Identity: "This is [baby's name], [X] months old, [corrected age Y months] if preterm."
2. High-risk factors: "This baby is high risk because: [list - LBW / preterm / NICU / mother working / malnutrition / etc.]"
3. Growth: "Weight is [X] kg at [X]th centile. Length [X] cm at [X]th centile. Head circumference [X] cm at [X]th centile. [Normal / FTT / Microcephaly / Macrocephaly]."
4. Physical exam: "General physical examination is [normal / significant findings]. [State any abnormal findings found]."
5. Neurological: "Tone is [normal / hypo / hyper]. Primitive reflexes are [present and appropriate / abnormally persistent]. Parachute reflex [present / absent]."
6. Developmental: "Developmental assessment shows the baby is [on track / delayed] in [domains]. [State specific milestone achieved or missed]."
7. Vision/Hearing: "Red reflex [present bilaterally / absent]. Hearing response [present / absent]."
8. Red Flags: "Red flags identified: [list]. This child requires urgent referral to [specialist]."
9. Plan: "My management plan: [routine follow-up / nutritional support / referral to physiotherapist / OT / speech therapist / ophthalmologist / audiologist / pediatric neurologist / immunization catch-up / parent education on home stimulation]."

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DEVELOPMENTAL RED FLAGS - INSTANT RECALL FOR VIVA

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THE 3-SECOND SUMMARY (Memorize This)

"I performed pediatric screening of a high-risk infant in 9 steps: (1) Introduction and consent, (2) Observation without touching, (3) Focused history to identify high-risk factors, (4) Anthropometry and growth chart plotting, (5) Vital signs, (6) Systematic head-to-toe physical examination starting with cardiac and respiratory first, ears and throat last, (7) Neurological examination including tone, primitive reflexes, and postural tests, (8) Developmental screening using corrected age for all 4 domains, and (9) Special screenings for vision, hearing, nutrition, and immunization. I then summarized findings and formulated a referral and management plan."

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PEDIATRIC SCREENING: 0 TO 3 MONTHS IN THE COMMUNITY

Complete Age-Specific Step-by-Step Guide

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UNDERSTAND THIS AGE GROUP FIRST

• Congenital anomalies missed at birth
• Neurological problems (birth asphyxia, HIE effects)
• Metabolic disorders (PKU, hypothyroidism)
• Hearing and vision problems
• Developmental delays
• Feeding and weight gain problems

• Newborn visit (1st-2nd week of life)
• 4-6 week visit
• 6-8 week visit
• 3-month (12-week) visit

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BEFORE YOU BEGIN

Corrected Age = Chronological age - weeks premature Example: Baby born at 32 weeks, now 3 months old → Corrected age = 3 months - 2 months = 1 month corrected Assess milestones against a 1-month-old, not a 3-month-old.

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STEP 1: INTRODUCTION AND CONSENT

"Hello, I am [your name]. I am here for the baby's routine health screening today. I will check [baby's name]'s growth, general health, and development. May I begin?"

• Ask baby's name, date of birth, gestational age at birth, and birth weight
• Ask the mother to sit comfortably with the baby on her lap

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STEP 2: OBSERVE FIRST — WITHOUT TOUCHING

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STEP 3: FOCUSED HISTORY FOR 0-3 MONTHS

Antenatal History

• Any illness during pregnancy? (fever, rash, diabetes, hypertension, thyroid problems)
• Any TORCH infections? (Toxoplasma, Rubella, CMV, HSV)
• Drugs/alcohol/tobacco used during pregnancy?
• Any scans done? Any abnormalities found?

Birth History

• Gestational age at birth? (Preterm / Term / Post-term)
• Birth weight? (<2.5 kg = LBW = HIGH RISK)
• Did baby cry immediately? (No cry = birth asphyxia concern)
• Was baby admitted to NICU? For how long? Why?
• Any jaundice? Did baby need phototherapy or exchange transfusion?
• Any seizures after birth?
• Apgar score if known?

Feeding History (CRITICAL in this age group)

• Breastfed or formula? Exclusive breastfeeding?
• How often does baby feed? How long per feed?
• Does baby latch properly? Is the mother's breast feeling empty after feeds?
• Does baby fall asleep during feeds? Vomit after feeds?
• Has birth weight been regained? (Should regain by day 10-14)

Current Concerns

• Any concerns about the baby's vision, hearing, or movements?
• Is baby making sounds, smiling?
• Any constipation, diarrhoea, excessive crying?

Neonatal Screening Done?

• Heel-prick/blood spot test done? (PKU, hypothyroidism)
• Hearing screening done? (OAE)
• Hip screening done? (Ortolani/Barlow)

Immunizations

• BCG given at birth? (check for BCG scar on left upper arm)
• Hepatitis B birth dose given?
• Due for 6-week vaccines?

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STEP 4: ANTHROPOMETRY (MEASUREMENTS)

4A. Weight

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4B. Length

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4C. Head Circumference (OFC)

• OFC > 99.6th centile OR crossing 2 lines upward = Macrocephaly → Hydrocephalus
• OFC < 0.4th centile OR crossing 2 lines downward = Microcephaly → Brain pathology

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4D. After Plotting, State the Result:

"I have plotted weight, length, and head circumference on the WHO growth chart. The baby's measurements are at the [X]th centile. This is [normal / concerning for failure to thrive / concerning for microcephaly/macrocephaly]."

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STEP 5: VITAL SIGNS

• RR: Count visually by watching chest movements for full 60 seconds - do this BEFORE touching (while baby is still quiet)
• HR: Auscultate at apex with stethoscope for 60 seconds
• Temperature: Axillary thermometer for 3 minutes
• Hypothermia check: In LBW/preterm - feel the baby's feet; cold feet = hypothermia risk

"Periodic breathing in a newborn - irregular breathing with short pauses of 5-10 seconds - is NORMAL. True apnoea (pause >20 seconds, or with bradycardia/colour change) is ABNORMAL and a red flag."

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STEP 6: SYSTEMATIC PHYSICAL EXAMINATION

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6A. SKIN

• Erythema toxicum: Most common; irregular red blotchy rash; first 2-3 days; disappears
• Milia: Tiny white dots on nose/cheeks; blocked sebaceous glands; disappear in weeks
• Neonatal pustular melanosis: Vesicopustules at birth; resolves by 3 months

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6B. HEAD

• Caput succedaneum: Scalp oedema, crosses suture lines, present at birth, resolves in days
• Cephalhaematoma: Subperiosteal blood, does NOT cross suture lines, appears hours after birth, takes weeks to months to resolve
• Craniosynostosis: Premature fusion of sutures - feel for ridging along a suture line; abnormal head shape

• Anterior fontanelle (AF):
  • Location: junction of metopic + coronal + sagittal sutures (top of head)
  • Size: 4-6 cm at birth
  • Should be: Soft, flat, mildly pulsatile
  • Bulging AF = raised ICP → meningitis, hydrocephalus, vitamin A toxicity
  • Sunken AF = dehydration
  • Large AF = hypothyroidism, rickets, Down syndrome
  • Closes: 12-18 months
• Posterior fontanelle (PF):
  • Location: junction of sagittal + lambdoid sutures (back of head)
  • Size: <1 cm at birth; often fingertip-sized
  • Closes: By 6-8 weeks
  • Early closure = craniosynostosis; Large = hypothyroidism

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6C. EYES

Intermittent squint is NORMAL in the first 2-3 months as eye muscles mature. Constant squint at any age is abnormal.

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6D. EARS

• Position: Ear should sit with its top at or above the line drawn from the outer corner of the eye horizontally backward
  • Low-set ears = Down syndrome, renal anomalies, Turner syndrome
• Pre-auricular tags or sinuses = note and document
• Otoscopy: In infants, straighten ear canal by pulling pinna downward and backward
  • Look for TM: should be pearly-grey with visible light reflex (cone of light)

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6E. NOSE

• Infants are obligate nasal breathers - blocked nose = respiratory distress
• Check patency: baby should breathe comfortably with mouth closed
• Choanal atresia (bilateral): baby turns blue at rest, becomes pink when crying; cannot pass a soft NG tube through each nostril - EMERGENCY
• Nasal flaring = respiratory distress

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6F. MOUTH (examine late)

• Cleft palate: Must visualise the FULL palate with torch + tongue depressor; do NOT rely on palpation alone; must see the uvula is central and intact
• Tongue tie (ankyloglossia): Tongue cannot elevate; affects breastfeeding; heart-shaped tongue tip
• Thrush (oral candidiasis): White patches on tongue/buccal mucosa that do NOT wipe off easily; treat with nystatin drops
• Sucking reflex: Place a clean fingertip in the mouth; strong rhythmic sucking should be present; weak suck = neurological concern
• Gag reflex: Touch back of tongue; should gag

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6G. NECK

• Neck muscle tone: In this age group - baby should be able to lift and turn the head when prone (present from birth)
• Lymphadenopathy: Note size, consistency, tenderness
• Sternocleidomastoid (SCM) muscle: Feel for a lump/tightness = SCM haematoma → torticollis (head tilted to one side) → refer for physiotherapy
• Webbed neck: Turner syndrome, Noonan syndrome
• Neck stiffness: Resist passive neck flexion = meningism → URGENT

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6H. CARDIOVASCULAR (While baby is quiet - do this early)

• Look for cyanosis, visible precordial impulse, respiratory distress with feeding

• Apex beat: Normally 4th left intercostal space, midclavicular line
• Check for thrills

• Listen at all 4 valve areas with diaphragm, then bell
• Normal HR: 100-160 bpm
• Murmur: A soft systolic murmur in first 24-48 hours may be closing ductus arteriosus - usually resolves. Persistent or harsh murmur after 6 weeks = refer
• Femoral pulses: Palpate both femoral pulses and brachial simultaneously
  • Absent/weak femoral pulse = Coarctation of aorta - URGENT
• Capillary refill time: Press sternum for 5 seconds; release; normal = <2 seconds

• Persistent central cyanosis
• Poor feeding, sweating during feeds, fatigue
• Failure to gain weight
• Fast breathing at rest
• Absent femoral pulses

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6I. RESPIRATORY

• Tachypnoea = RR >60/min
• Grunting (audible expiratory grunt) = very ill baby trying to maintain FRC
• Intercostal/subcostal recessions = laboured breathing
• Nasal flaring
• See-saw breathing (chest sinks, abdomen rises) = paradoxical breathing in preterm

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6J. ABDOMEN

• Umbilicus: Cord should fall by 1-2 weeks. Infection (omphalitis) = redness, discharge, foul smell - DANGEROUS in neonate (can cause portal vein thrombosis, septicaemia)
• Umbilical hernia: Soft bulge at umbilicus, expands with crying - common, usually resolves by 1-2 years
• Distension; visible peristalsis (obstruction)

• Liver: Normally palpable 1-2 cm below right costal margin in infants - mark in cm
• Spleen: Feel from right iliac fossa upward
• Kidneys: Bimanual palpation (enlarged = hydronephrosis)
• Any masses

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6K. GENITALIA

• Are both testes in the scrotum? If not palpable: start palpating ABOVE the inguinal canal working downward
• Hydrocele (transilluminates with torch light): common in first months, usually resolves
• Hypospadias: Meatal opening on underside of penis
• Phimosis: Normal in newborns - foreskin naturally adherent; do not forcibly retract

• Vaginal discharge/pseudo-menses in first 1-2 weeks = normal (maternal oestrogen withdrawal)
• Labial adhesions

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6L. HIPS (CRITICAL - Done at Every Visit Until 4 Months)

1. Baby supine, hip and knee flexed to 90°
2. Adduct the hip (bring knee toward midline)
3. Apply gentle downward posterior pressure through the knee
4. CLUNK felt/heard = hip dislocates = POSITIVE

1. Baby supine, hip and knee flexed to 90°
2. Abduct the hip (bring knee outward) while lifting the greater trochanter anteriorly with middle finger
3. CLUNK felt/heard = hip reduces = POSITIVE

"I am performing Barlow and Ortolani tests to screen for Developmental Dysplasia of the Hip. This must be done at 6-14 days and then monthly until 4 months of age."

• Limited hip abduction (<60°)
• Asymmetric skin folds (unequal gluteal/inguinal folds)
• Leg length discrepancy (Galeazzi sign - knees at unequal heights when hips and knees flexed)

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6M. SPINE AND BACK

• Turn baby prone
• Inspect spine for scoliosis, midline defects, dimple/sinus/tuft of hair (→ spina bifida occulta)
• Mongolian spots: blue-grey, sacral - DOCUMENT to avoid confusion with bruising

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STEP 7: NEUROLOGICAL EXAMINATION (0-3 MONTHS)

7A. TONE ASSESSMENT

• Lay baby supine; hold both wrists; slowly pull to sitting
• Newborn: Marked head lag is NORMAL
• 2 months: Partial head lag
• 4 months: NO head lag; head should be in line with trunk
• Complete head lag after 4 months = RED FLAG

• Hold baby prone on your palm in the air
• Normal: Baby extends trunk with head at least in line with the body; limbs semi-extended
• Abnormal: Baby droops like an inverted U = HYPOTONIA

• Hold baby upright under the axilla
• Normal: Some bearing of weight through legs; legs slightly flexed
• Abnormal: Legs scissor (cross) = hypertonia → cerebral palsy concern

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7B. PRIMITIVE REFLEXES — AGE-SPECIFIC FOR 0-3 MONTHS

• Any ASYMMETRY of reflexes = RED FLAG → brachial plexus injury, fracture, hemiplegia
• Absent Moro = severe neurological depression
• Absent sucking/rooting = feeding will be affected, neurological concern

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7C. PARACHUTE REFLEX - NOT YET PRESENT AT THIS AGE

"The parachute reflex does NOT appear until 6-9 months. I will check for it at the 6-9 month visit."

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STEP 8: DEVELOPMENTAL SCREENING (0-3 MONTHS)

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COMPLETE DEVELOPMENTAL MILESTONES: 0-3 MONTHS

NEWBORN (Birth - 2 weeks)

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1 MONTH

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2 MONTHS

Absence of social smile by 8 weeks = RED FLAG requiring urgent developmental evaluation

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3 MONTHS

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DEVELOPMENTAL RED FLAGS FOR 0-3 MONTHS

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STEP 9: HEARING SCREENING (0-3 MONTHS)

At Birth / Newborn Visit:

"I will confirm whether universal newborn OAE (Otoacoustic Emission) screening was done before hospital discharge. If not done, I will arrange referral for hearing screening now."

Bedside Screening in Community (if formal OAE not done):

• Wait until baby is in quiet alert state (not sleeping, not crying)
• Make a soft sound (rattle, bell, clap) 30-45 cm from the ear, behind and outside visual field
• Normal responses:
  • Newborn: blink, startle, stiffening, eye widening
  • 1 month: slight head turn, quieting
  • 2-3 months: turning head toward sound, widening of eyes, cessation of sucking

HIGH-RISK for Hearing Loss in this age group - Refer ALL for formal OAE/ABR:

• NICU stay >5 days
• Aminoglycoside antibiotics given
• Neonatal meningitis or encephalitis
• Severe neonatal jaundice (exchange transfusion)
• Family history of childhood-onset hearing loss
• Craniofacial anomalies (low-set ears, cleft palate)
• TORCH infections

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STEP 10: VISION SCREENING (0-3 MONTHS)

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STEP 11: NEONATAL METABOLIC SCREENING (0-3 MONTHS)

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STEP 12: FEEDING AND NUTRITION ASSESSMENT

• Is baby exclusively breastfed? (WHO recommends exclusive breastfeeding for 6 months)
• Count wet nappies: 6+ wet nappies per day = adequate hydration and milk intake
• Stools: Breastfed stools are yellow/mustard, seedy, soft - up to 10 per day OR can be every 5-7 days (both normal). Formula stools are paler and firmer.
• Weight gain: Should be 25-30 g/day in first 3 months
• If not breastfeeding: Review formula preparation - correct dilution, clean water, sterilised bottles

• Not regaining birth weight by day 14

• 10% weight loss from birth weight at any time

• Fewer than 6 wet nappies per day
• Baby lethargic, not waking for feeds
• Persistent weight loss or flat weight curve

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STEP 13: IMMUNIZATION STATUS

"I will check the immunization card. BCG scar should be visible on the left upper arm. If the baby is 6 weeks old, I will ensure first set of vaccines (DPT, OPV, Hib, PCV, Rotavirus, Hep B) are given today or arranged."

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STEP 14: PARENT COUNSELLING (ALWAYS END WITH THIS)

1. Feeding: Continue exclusive breastfeeding; feed on demand (8-12 times/24 hours)
2. Safe sleep: Baby on back, not prone; no soft bedding; not too hot/cold
3. Skin care: Gentle bathing; no talcum powder; umbilical cord kept dry and clean
4. Stimulation at home:
   • Talk, sing, and make eye contact with baby every day
   • Tummy time (supervised) from day 1 - 2-3 minutes at a time, several times a day
   • Respond to baby's cries consistently
5. Danger signs - when to come immediately:
   • Not feeding at all
   • Lethargic, difficult to wake
   • Fast breathing or difficulty breathing
   • Convulsions/seizures
   • Fever >38°C or temperature <36°C
   • Yellow skin and eyes (jaundice)
   • Umbilicus red or smelly
6. Next visit: State when the next visit/vaccine is due

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STEP 15: SUMMARIZE AND DOCUMENT

"I have completed the 0-3 month community screening of this infant. To summarize:

• This baby is [X] weeks/months old, corrected age [X] if preterm
• Growth: Weight [X] kg at [centile]; Length [X] cm; HC [X] cm - [normal/abnormal]
• Physical examination: [normal/significant findings]
• Neurological: Tone [normal/hypo/hyper]; Primitive reflexes [present/symmetric/asymmetric]
• Developmental milestones: [on track/delayed in which domain]
• Vision: Red reflex [present/absent]; Tracking [present/absent]
• Hearing: [response present/absent]
• Feeding: [adequate/inadequate]
• Immunizations: [up to date/gaps identified]
• Red flags identified: [list]
• My plan: [routine follow-up at 6 weeks/refer to pediatric neurologist/OT/PT/audiologist/ophthalmology/nutritional rehabilitation]"*

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QUICK REVISION TABLE: 0-3 MONTHS AT A GLANCE

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