Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Wellbaby
Well-baby Care - Key Features
1. Measure and chart growth parameters, including head circumference, at each assessment; examine appropriate systems at appropriate ages, with the use of an evidence-based pediatric flow sheet such as the Rourke Baby Record.
2. Modify the routine immunization schedule in those patients who require it (e.g., those who are immunocompromised, those who have allergies).
3. Anticipate and advise on breast-feeding issues (e.g., weaning, returning to work, sleep patterns) beyond the newborn period to promote breast-feeding for as long as it is desired.
4. At each assessment, provide parents with anticipatory advice on pertinent issues (e.g., feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues).
5. Ask about family adjustment to the child (e.g., sibling interaction, changing roles of both parents, involvement of extended family).
6. With parents reluctant to vaccinate their children, address the following issues so that they can make an informed decision:
- their understanding of vaccinations.
- the consequences of not vaccinating (e.g., congenital rubella, death).
- the safety of unvaccinated children (e.g., no Third World travel).
7. When recent innovations (e.g., new vaccines) and recommendations (e.g., infant feeding, circumcision) have conflicting, or lack defined, guidelines, discuss this information with parents in an unbiased way to help them arrive at an informed decision.
8. Even when children are growing and developing appropriately, evaluate their nutritional intake (e.g., type, quality, and quantity of foods) to prevent future problems (e.g., anemia, tooth decay), especially in at-risk populations (e.g., the socioeconomicaly disadvantaged, those with voluntarily restricted diets, those with cultural variations)
Nutrition
• Exclusive breastfeeding recommended in first 6 months, and breastfeeding (with complementary foods) is promoted as long as desired
• Vitamin D 400 IU/day for breastfed infants (800 IU/day in Northern communities)
• Solids: introduction at 6 months
- o Iron containing foods (cereals, meat, egg yolk, tofu)
- o Fruits and veggies to follow
- o Introduce cow’s milk products at 9 months
- o No egg white, nut products, or honey until 12 months
• Milk
- o Switch from formula to homo milk (500-750 mLs/day) at 12 months
- o Transition to 1% or 2% milk (~500 mLs/day) at 2-3 years
- o Discontinue bottles by 18 months
• Avoid sweetened juices/liquids
• Inquire about vegetarian diets
• Transition to lower fat diet after age 2 as per Canada’s Food Guide
Breastfeeding
• Benefits
- o Infant: reduced risk of infections (GI, respiratory, UTIs, AOM, meningitis), SIDS, obesity, T1DM, childhood CA (leukemia, lymphoma), IBD, Celiac disease, heart and liver diseases in adulthood
- o Mother: decreased risk of breast and ovarian CA, decreased risk of DM improved bone health, weight loss, lactational amenorrhea
• Weaning
- o Eliminate one BF session every 2-5 days (start with midday feed), supplement with age appropriate alternative (see nutrition)
- o Another caregiver could introduce the bottle, as some babies initially refuse the bottle when the mother’s breast is available
• Return to work: pumping every few hours will help prevent mastitis
• Tips to facilitate sleep: keep baby awake with frequent feeds in evening, bedtime rituals (ie. bath), keep lights low and do not talk to or stimulate baby during nighttime feeds
Education/Advice
• Sleep safety
- o Place on back to sleep (place head in different positions on alternate days), supervised tummy time while awake
- o Soft mattresses, pillows, comforters, stuffed toys and bumper pads should not be used in cribs
- o Rooming-sharing lowers the risk of SIDS
- o Avoid bed-sharing, overheating, and maternal or second-hand smoke to decrease the risk of SIDS
- o Pacifier use may decrease risk of SIDS and should not be discouraged in the first year
• Medications
- o Antipyretics: acetaminophen 15 mg/kg/dose
- o Ibuprofen 10 mg/kg/dose
- o Do not use OTC cough/cold medication
Development
| Age | Gross Motor | Fine Motor | Speech | Social |
|---|---|---|---|---|
| 2m | Prone-lifts head and pushes up on arms | Coos | Smiles, follows | |
| 4m | Holds head steady, rolls F to B | Reaches for and holds objects, hands to mouth | Begins to babble | Laughs |
| 6m | Begins to sit without support, rolls B to F | Palmar grasp, hand to hand transfer | Babbles, responds to name | Stranger anxiety |
| 9m | Gets into sitting position, sits independently, pulls to stand, stands holding on | Finger-thumb grasp | Mama, dada, baba | Peek-a-boo, bye-bye |
| 12m | Independent standing, cruising, first steps | Pincer grasp, throws | Single words (2) | Drinks from cup |
| 18m | Walks independently, stairs with help | Scribbles, tower of 3 blocks | Single words (10), follows simple commands | Points to show interest, points to body parts, uses spoon |
| 2y | Runs, up stairs 2 feet/step, kicks ball | Draws straight lines, tower of 6 blocks | 2 word phrases, follow 2-step commands | Undresses, knows age/sex |
| 3y | Up stairs 1 foot/step, down 2 feet/step, stands on 1 foot, jumps | Draws circle, turns book pages one at a time | 3 word phrases, says name, age, and sex, counts to 10 | Dresses/undresses self, toilet trained |
Pediatric Exam Includes
• Growth: correct percentiles until 24-36 months if gestation <37 weeks, regain BW by 1-3 weeks
• Eyes: red reflex, corneal light reflex, cover-uncover test and inquiry for strabismus (6+ months)
• Hearing inquiry/screening
• Fontanelles: posterior closed by 2 months, anterior closed by 18 months
• Muscle tone
• Hips (until at least 1 year, or until child can walk)
• Snoring/tonsils
Immunization
• Understanding vaccines
- o Infants can respond to 10,000 different antigens at any one time, giving 6 vaccines does not add, significantly, to the daily load
• Not vaccinating
- o Protection from herd immunity declines, as vaccination rates decline
- o Diseases only one flight away – massive outbreaks (eg. diptheria in Russia in the 90’s and polio in middle east last year with >500 paralyzed) due to lapses in immunization
- o Advise against 3rd world travel
• Some contraindications
- o Immunocompromised: live vaccines, consult specialist
- o IgE-mediated chicken or egg allergy is a contraindication to influenza, yellow-fever and rabies vaccines (GI intolerance in NOT)
- o Anaphylaxis to neomycin or gelatin is a contraindication to MMR