Well-baby Care – RBR / CPS2013

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.

  • Chart wt, ht, head circumference on growth scale
  • Correct percentiles if born preterm until 24-36mo
  • Well baby checks are required at 1week, 2months, 4 months, 6 months, 12 months, 18 months, 2-3 years& 4-5 years. Add additional visits if the child is unwell or needs closer monitoring
FFT
  • Wt <5%ile for age/sex on >= 1 occasion
  • Wt <5% of ideal body wt for age/sex
  • Wt depressed in proportion to ht
  • Wt trajectory crossing 2 or more major %ile lines – especially away from 50%ile
  • Consider if rate of daily wt gain < expected
  • 0-3 mo: 26-31g/day
  • 3-6 mo: 17-18g/day
  • 6-9 mos: 12-13g/day
  • 9-12 mos: 9-13g/day
  • 1-3 yr: 7-9g/day

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)
    • psuedostrabismus: front a flat nasal bridge
    • Hirschberg test – normal symmetric placement of the corneal light reflex
    • look for corneal light reflex
      • Normal: Reflex falls on nasal portion of each Cornea
      • esotropia: On Deviated eye, reflex displaced lateral or temporal
      • exotropia: On deviated eye, reflex displaced medially
      • hypertropia: reflex at different height
  • Hearing inquiry/screening
  • Fontanelles: posterior closed by 2 months, anterior closed by 18 months
  • lungs, abdomen, umbilicus
  • Muscle tone
  • Hips (until at least 1 year, or until child can walk), testicles, foreskin
  • Snoring/tonsils

2 Modify the routine immunization schedule in those patients who require it (e.g., those who are immunocompromised, those who have allergies).

Immunization

  • Understanding vaccines
    • 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
    • Protection from herd immunity declines, as vaccination rates decline
    • 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
    • Advise against 3rd world travel
  • Some contraindications
    • Immunocompromised: live vaccines, consult specialist
    • IgE-mediated chicken or egg allergy is a contraindication to influenza, yellow-fever and rabies vaccines (GI intolerance in NOT)
    • Anaphylaxis to neomycin or gelatin is a contraindication to MMR

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.

Breastfeeding

  • Benefits
    • 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
    • Mother: decreased risk of breast and ovarian CA, decreased risk of DM, improved bone health, weight loss, lactational amenorrhea
  • Weaning
    • Eliminate one BF session every 2-5 days (start with midday feed), supplement with age appropriate alternative (see nutrition)
    • 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

Two herbal treatments that seem to increase the milk supply are fenugreek and blessed thistle, in the following dosages:

Fenugreek
: 3 capsules 3 times a day
Blessed Thistle: 3 capsules 3 times a day, or 20 drops of the tincture 3 times a day

  • Fenugreek and blessed thistle seem to work better if you take both, not just one or the other.
  • Fenugreek and blessed thistle work quickly. If they do work, you will usually notice a difference within 12- 24 hours of starting taking them. If not, they probably won’t work.
  • Fenugreek is often sold as a combination with thyme. Do not buy this combination, but try to get the capsules with fenugreek alone.

Fenugreek and blessed thistle seem also to work better in the first few weeks than later. In fact they tend to work best in the first week. Domperidone works better after the first few weeks. 

  • You can take fenugreek and blessed thistle together with domperidone if you feel they are helping. If you take both the herbs and domperidone, take domperidone 3 tablets three times a day at the same time as you take the herbs.
  • If you are ready to stop fenugreek and blessed thistle, you can probably stop suddenly, or wean off over a week or so.
  •  Fenugreek does not cause low blood sugar. Where this rumour came from is unknown.

Some Lactation Teas may be effective for some mothers. Again, with no standardization and little empirical evidence it is hard to know. We do hear from many mothers that have helped to increase their milk supply. These include: mother’s milk teas, nursing teas, lactation teas. Certainly, it cannot hurt to try.

Food that may help:

  • Eating oatmeal daily,
  • garlic in moderation,
  • ginger in moderation,

are all thought to help milk supply. Again, it cannot hurt to eat oatmeal or take garlic or ginger.


Dr. Jack Newman’s All-Purpose Nipple Ointment (APNO)

  • Bactroban 2% ointment – 15gm
  • Betamethasone 0.1% ointment – 15gm
  • Miconazole powder to final concentration of 2%

Apply sparingly after feeding, TID. Do not wipe off


4 At each assessment, provide parents with anticipatory advice on pertinent issues (e.g., feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues).

Feeding
  • No honey in the first year
  • No beets, carrots, spinach, turnips before 6mo (contain nitrates)
  • Avoid dry, solid, round, smooth, sticky foods that can cause choking and sugary foods / drinks
  • Transition to solid foods when developmentally ready:
    • transition from sucking to spoon feeding
    • Holds head up well
    • sits with little help
    • opens mouth when food offered
    • Turns head to refuse food
    • Introduce new foods one at a time Q3-5d to monitor for reactions
General Principles Exclusive BF x 6mo vs total duration
  • Introduce solids no later than 6mo – iron sources first: cereals, meat, eggs, tofu
  • Potential allergens: citrus fruits, cow’s milk, corn, egg whites, wheat, chocolate, nuts, peanuts, shellfish
  • Evidence supports introduction of allergenic foods (at home) between 4-6 mo to reduce the risk of food allergy but against complimentary foods before 12 week
  • complimentary foods at 4-6 months may include cow’s milk protein (except whole cow’s milk), egg, soy, wheat, peanut, fish, shellfish
  • Avoidance of allergenic foods during pregnancy and lactation not recommended
  • Totral duration of BF may be more important for allergy prevention than exclusive BF
  • consider partial hydrolysate or extensively hydrolyzed formula in high risk children when bf
  1. At 9mo, offer high fat yogurt, cottage cheese, grated hard cheese,
  2. Introduce whole milk from 9-12mo, limit milk products to 720ml/d (risk of iron deficiency anemia)
    • If feeding with formula – use iron-fortified formulas 5oz/kg/d for first 2 wk
    • Start with iron-fortified infant cereals, grain products such as dry toast or crackers, pureed cooked yellow, green, orange vegetables, fruits, ripe mashed fruits
    • Pureed cooked meat, fish, chicken, tofu, mashed beans, egg yolk
  3. 9-12 mo: Plain cereals, whole grain bread, rice, pasta, Soft mashed, cooked vegetables, soft fresh fruits, peeled, seeded, diced, canned fruitsMinced / diced meat, fish, chicken, tofu

Education/Advice

  • Sleep safety
    • Place on back to sleep (place head in different positions on alternate days), supervised tummy time while awake
    • Soft mattresses, pillows, comforters, stuffed toys and bumper pads should NOT be used in cribs
    • Rooming-sharing lowers the risk of SIDS
    • Avoid bed-sharing, overheating, and maternal or second-hand smoke to decrease the risk of SIDS
    • Pacifier use may decrease risk of SIDS and should not be discouraged in the first year
  • Medications
    • Antipyretics: acetaminophen 15 mg/kg/dose
    • Ibuprofen 10 mg/kg/dose
    • Do not use OTC cough/cold medication
  •  Safety Issues
    • Car seat, helmets, bath safety
    • 2nd hand smoke
    • Child proofing, keep OTC meds and poisons out of reach

Milestones
  • Provide anticipatory info for milestones
  • Milestones should be monitored closely
  • Delay in achieving age-appropriate milestones may unmask an underlying developmental / learning disorder
Development surveillance:
  • assessing risk (asking re parental concerns re their child’s development, observing the child, identifying risk/protective factors, documenting milestone attainment)
Development screening:
  • standardized tools
Red flag approach
  • Fair evidence for most milestone items including “no parent/caregiver concerns”
  • RBR 18mo developmental milestones
  • Autism spectrum disorder screening at 18-24 mo – M-CHAT-R/F
Age Gross Motor Fine Motor Language Social
2mo Lifts head / chest when lying on stomach Vision tracks past midline Coos, reacts to sounds Recognizes parents, smiles
6mo Sits alone Transfers btw hands Babbles Stranger anxiety
9mo Crawls, pulls to stand up 3 finger pincer grasp Mama/dada Waves, plays pat-a-cake
12mo Cruises, walks 2 finger pincer grasp Mama/dada specifically One step command
18mo Runs, kicks ball Build tower of 2-4 cubes Names common things Copies parents
2yr3yr Jumps, walks up/down stairs with helpUp stairs 1foot/step, down 2 feet/step, stands on 1 foot, jumps Builds tower of 6 cubesDraw circle, turns book pages one at a time Two word phrases3 word phrases, says name, age, and sex, counts to 10 Obeys 2step commands, undresses alone, knows age/sexDresses / undresses self, toilet trained

5 Ask about family adjustment to the child (e.g., sibling interaction, changing roles of both parents, involvement of extended family).

  • Always ask about family adjustment, include mood disorders

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).

  • Discuss importance of vaccination & Addressing parental reluctance
    • ethical dilemma
    • risk and benefit: risk with VS. w/o vaccine
    • correct misconceptions
    • Addressing parents’ concerns: Do multiple vaccines overwhelm or weaken the infant’s immune system? Offit et al. Padiatrics 2002; 109(1): 124-129
    • discuss vaccines individually
    • pt-centered: flexible schedule
  • Pain reduction:
    • Sweet-tasting solutions, least painful vaccine brand, topical anesthetics: BF, Vit D drop (sweet), or sweeten juice
  • Fever advice
    • Tylenol can be used as anti-pyretic 10-15mg/kg Q4-6hr

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.

Good article:


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 socioeconomically disadvantaged, those with voluntarily restricted diets, those with cultural variations).

  • Screen for anemia at 6 to 12 mo in at-risk population (lower socioeconomic status, Asians, First Nations, Low Birth weight, infant fed with whole cow’s milk in first year of life

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
    • Iron containing foods (cereals, meat, egg yolk, tofu)
    • Fruits and veggies to follow
    • Introduce cow’s milk products at 9 months
    • No egg white, nut products, or honey until 12 months
  • Milk
    • Switch from formula to homo milk (500-750 mLs/day) at 12 months
    • Transition to 1% or 2% milk (~500 mLs/day) at 2-3 years
    • 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

References:
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Posted in 99 Priority Topics, 99 Well-baby Care, FM 99 priority topics, OB

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