Paeds Cases · growth-development-and-behaviour
Floppy infant OSCE — localisation, safety and family counselling
OSCE on floppy infant assessment: bedside localisation, red-flag recognition, urgent pathway and closed-loop counselling.
osce short clinical and communication station
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Target exams
RACP General PaediatricsRACP DCEMRCPCH ClinicalRCPSC Pediatrics
Prompt
Station A is a 10-minute assessment of a 3-month-old with progressive floppiness. Station B is 8 minutes counselling parents after you identify a peripheral progressive pattern.
Station objectives
- Distinguish tone, strength and laxity at the bedside. [1]
- Localise central versus peripheral patterns using power, reflexes and posture. [1] [2]
- Recognise progressive SMA-pattern red flags and protect airway/feeding. [5] [9]
- Counsel concurrent urgent genetics/neuromuscular referral without false reassurance. [9]
- Use teach-back and a closed-loop safety-net plan. [5]
Candidate brief
You are the doctor in a paediatric assessment unit. Station A: examine and reason aloud with a parent and infant mannequin/actor. Station B: explain findings and plan. [1]
Station A — Clinical assessment (10 minutes)
Parent script: “She was smiling last month but now her head flops and she tires with feeds. A friend said low tone is common.” [1]
Expected candidate actions: [1]
- Observe breathing, posture, spontaneous antigravity movement before handling. [1]
- Assess passive tone, traction/suspension manoeuvres, power, deep tendon reflexes, tongue. [1] [2]
- Screen suck–swallow, cough and work of breathing; pause oral feeds if unsafe. [5]
- State working localisation: progressive peripheral pattern ± SMA concern if areflexia/fasciculations. [9]
- List same-day actions: stabilise, SMN1 pathway, neuromuscular referral — not “review next month.” [9]
Station B — Counselling (8 minutes)
Tasks: [5]
- Name the problem as a pattern needing urgent work-up, not a casual “floppy baby” label. [1]
- Explain that social alertness does not exclude serious neuromuscular disease. [9]
- Describe airway/feeding protection in plain language. [5]
- Outline tests that change management this week and who owns the referral. [9]
- Teach-back return precautions: harder breathing, blue spells with feeds, weaker cry, fewer movements. [5]
Examiner marking grid
| Domain | Fail | Borderline | Pass |
|---|---|---|---|
| Localisation | Calls everything “tone problem” without power/reflexes | Mentions central vs peripheral incompletely | Clear central vs peripheral with discriminators |
| Safety | Allows oral feeds despite weak cough | Mentions feeding vaguely | Explicit airway/feeding plan |
| Urgency | Reassures progressive areflexic phenotype | Orders tests without pathway ownership | Time-critical SMA pathway + named referral |
| Communication | Jargon, no teach-back | Partial plan | Clear, compassionate, closed-loop |
Common candidate errors
- Equating a social smile with neuromuscular safety. [9]
- Labelling “benign congenital hypotonia” as a final diagnosis. [2]
- Waiting for botulism laboratory confirmation before treatment in the descending-paralysis branch. [16]
- Forgetting to examine the mother when congenital myotonic dystrophy is possible. [17]
References
- [1]Peredo DE, Hannibal MC The floppy infant: evaluation of hypotonia. Pediatrics in review, 2009.PMID 19726697
- [2]Bodensteiner JB The evaluation of the hypotonic infant. Seminars in pediatric neurology, 2008.PMID 18342256
- [5]Laverty CG Hypotonia in the Newborn Infant. Pediatric clinics of North America, 2025.PMID 40619196
- [9]Finkel RS, Mercuri E, Darras BT Nusinersen versus Sham Control in Infantile-Onset Spinal Muscular Atrophy. The New England journal of medicine, 2017.PMID 29091570
- [16]Sarintra N, Ekdahl R, Sanders SC More Than Just a Floppy Baby: Maintaining High Clinical Suspicion of Infant Botulism. Cureus, 2026.PMID 41728439
- [17]Suzui R, Wada I, Matsubara M Undiagnosed Maternal Myotonic Dystrophy Type 1 Revealed by Congenital Myotonic Dystrophy in the Neonate. Cureus, 2026.PMID 42037975