Infant health supervision birth to 3 months — branching viva · Paeds Vivas

Prompt

You are the paediatric registrar in a community clinic. The examiner moves from a day-5 breastfed infant with weight loss and jaundice to a 2-month visit with unsafe sleep and maternal low mood.

Branch A — Day-5 infant (6–8 minutes)

Examiner: "Day-5 exclusive breastfeeding, 11% weight loss, mild jaundice. What do you do first?" [1]

Strong candidate:

Doorway: is the infant well or unwell?
If unwell → ABCDE, glucose, sepsis pathway.
If currently stable → structured assessment: output, alertness, feed observation, full exam, measure bilirubin, plot weight in nomogram context, feeding rescue plan, early reweigh. [1]

Prompts if stuck:

"How do you decide admission?"
"What exactly do you tell the mother about breastfeeding tonight?" [1]

Fail actions: visual jaundice only; "any loss under 15% is fine"; no reweigh plan. [1]

Branch B — Screening and examination (4 minutes)

Examiner: "What must not be missed on exam and results review in the first weeks?" [1]

Strong candidate:

Red reflex, femoral pulses, hips, heart, skin for bruises/jaundice.
Close bloodspot, hearing and CCHD pulse-ox loops.
Corrected growth for prematurity when relevant. [1]

Branch C — Two-month visit counselling (6 minutes)

Examiner: "Parents bed-share; mother is tearful. Vaccines due. Run the counselling." [1]

Strong candidate:

Safe sleep: supine, firm flat surface, no soft bedding, room-share not bed-share, smoke-free; negotiate without shame.
Maternal depression: acknowledge, assess safety, warm handover.
Immunise unless true contraindication; mild snuffles not a reason to cancel casually.
Teach-back and safety-net. [1]

Examiner scoring domains

Domain	What earns marks
Threat-first thinking	Leaves well-child script when unwell
Growth/feeding	Nomogram context + actionable plan
Jaundice	Measure and plot by age in hours
Prevention package	Sleep, screens, vaccines, mood
Communication	Clear, non-judgemental, teach-back

References

[1]Moon, Rachel Y Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics, 2022.PMID 35726558
[5]Kemper, Alex R Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics, 2022.PMID 35927462
[6]Flaherman, Valerie J Early weight loss nomograms for exclusively breastfed newborns. Pediatrics, 2015.PMID 25554815
[7]Rafferty, Jason Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics, 2019.PMID 30559118
[12]Shane, Andi L Neonatal sepsis. Lancet (London, England), 2017.PMID 28434651
[9]Mahle, William T Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics, 2012.PMID 22201143
[3]Meek, Joan Younger Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics, 2022.PMID 35921640

Branch A — Day-5 infant (6–8 minutes)

Examiner: "Day-5 exclusive breastfeeding, 11% weight loss, mild jaundice. What do you do first?" [1]

Strong candidate:

Doorway: is the infant well or unwell?

If unwell → ABCDE, glucose, sepsis pathway.

If currently stable → structured assessment: output, alertness, feed observation, full exam, measure bilirubin, plot weight in nomogram context, feeding rescue plan, early reweigh. [1]

Prompts if stuck:

"How do you decide admission?"

"What exactly do you tell the mother about breastfeeding tonight?" [1]

Fail actions: visual jaundice only; "any loss under 15% is fine"; no reweigh plan. [1]

Branch C — Two-month visit counselling (6 minutes)

Examiner: "Parents bed-share; mother is tearful. Vaccines due. Run the counselling." [1]

Strong candidate:

Safe sleep: supine, firm flat surface, no soft bedding, room-share not bed-share, smoke-free; negotiate without shame.

Maternal depression: acknowledge, assess safety, warm handover.

Immunise unless true contraindication; mild snuffles not a reason to cancel casually.

Teach-back and safety-net. [1]

Examiner scoring domains

Domain	What earns marks
Threat-first thinking	Leaves well-child script when unwell
Growth/feeding	Nomogram context + actionable plan
Jaundice	Measure and plot by age in hours
Prevention package	Sleep, screens, vaccines, mood
Communication	Clear, non-judgemental, teach-back

References

[1]Moon, Rachel Y Sleep-Related Infant Deaths: Updated 2022 Recommendations for Reducing Infant Deaths in the Sleep Environment. Pediatrics, 2022.PMID 35726558
[5]Kemper, Alex R Clinical Practice Guideline Revision: Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation. Pediatrics, 2022.PMID 35927462
[6]Flaherman, Valerie J Early weight loss nomograms for exclusively breastfed newborns. Pediatrics, 2015.PMID 25554815
[7]Rafferty, Jason Incorporating Recognition and Management of Perinatal Depression Into Pediatric Practice. Pediatrics, 2019.PMID 30559118
[12]Shane, Andi L Neonatal sepsis. Lancet (London, England), 2017.PMID 28434651
[9]Mahle, William T Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics, 2012.PMID 22201143
[3]Meek, Joan Younger Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics, 2022.PMID 35921640