Sarah gave birth to a healthy baby girl, Ruby, and went home when Ruby was a day old. On the fifth day of Ruby’s life, a midwife came to her home and performed the heel prick test. A couple of days later the hospital called Sarah to say that Ruby’s TSH level was raised at 12.2mU/L, and she needed to go to the hospital for a scan and another blood test. This was quite worrying for Sarah as she felt Ruby was doing absolutely fine at home. Sarah took Ruby to the children’s ward the next day for a repeat blood test and scan. The scan was quite frightening as the machine was so big and Ruby looked so small, but the nurse practitioner explained everything to Sarah, and that they usually see a couple of babies like Ruby every week, which made Sarah feel a little better. Ruby’s second blood test still had a raised TSH level, so the nurse practitioner sat down with Sarah and explained the diagnosis of congenital hypothyroidism. Ruby’s scan showed that her thyroid gland hadn’t developed properly. She explained the need for Ruby to take oral levothyroxine, which she prescribed, and showed Sarah how to give. Further information was given with leaflets for Sarah to take home, and support groups. A further clinic appointment was made to see the Consultant with the nurse practitioner, and Sarah left the hospital with Ruby, confident in the extra care that she now needs to give.

• If Ruby had not had her heel prick test, what signs and symptoms might she develop which may cause her parents to become concerned?