Pediatric Primary Care (17 page)

5.  Should have some supervised, “tummy” play time (15-20 minutes/session).

6.  Ask about behavior after feedings to determine any colic or reflux.

VI. SOCIAL DEVELOPMENT

A.  Babies have specific sounds/cries for specific needs. They will fuss/cry 1-2 hours/day. Providing for infant's needs should stop the crying. Crying gradually decreases by 3 months of age.

B.  Infant needs holding; touching; feeding; dry, clean diaper; warm, yet comfortable environment.

C.  Discourage taking baby to public places or visiting relatives since infant has not been immunized. Sick adults should stay away from infant.

D.  Encourage mother to rest when baby rests/sleeps. Determine if night times are “awake times for the pair” and the mother is not getting her sleep.

VII. IMMUNIZATIONS (SEE
APPENDIX A
)

A.  If mother is HBsAg-, infant may not have received first hepatitis B vaccine in newborn nursery and will need to get it today or before 2 months of age. If infant received hepatitis B immunization in the nursery, he/she will need to get four hepatitis B immunizations.

B.  Infant should not have fever or fussiness from the immunization.

C.  Discuss importance of getting immunizations. Many parents are concerned about risks. One in eight parents in the United States refused at least one recommended vaccine for their child.

VIII. SAFETY/ANTICIPATORY GUIDANCE

A.  Sleep position “back to sleep.”

1.  Not safe for baby to sleep in adult bed.

2.  Discuss room temperature (comfortable), amount of clothing to put on baby (not to overdress infant).

3.  No pillows/toys in the crib that could potentially smother child.

4.  Federal motor vehicle safety tested and approved car seat: installed properly in backseat, facing backward in automobile. Contact local hospital, fire department, or local March of Dimes for car seat rental programs.

B.  No smoking around infant.

C.  Reassure parents they cannot spoil infant at this age.

D.  Discuss sibling jealousy and possible regression of toddler. Encourage parent to spend “special time” with older sibling.

E.  Discuss pet safety: Do not leave infant unattended near pet.

F.  Discuss toys.

G.  Discuss what to look for when choosing babysitter or daycare (e.g., handwashing, number of children, sick policy, feeding techniques).

H.  One-piece pacifiers only, discuss appropriate use of pacifiers. Should not pin them on a string to baby's clothing, wash with soap and water if they fall out of the baby's mouth, do not lick or moisten it prior to giving to baby.

I.  May give 1 oz of sterile water in 24 hours if stools are very hard. No corn syrup (Karo) for constipation.

J.  No solids.

K.  Remind parents of when and how to call healthcare provider. Review call-in phone policy and explain hours that are best to call office.

1.  Breathing difficulties.

2.  Seizures.

3.  Irritability.

4.  Poor feeding, vomiting.

5.  No urine in 12 hours, black or decreased bowel movements.

6.  Reddened, draining umbilical site.

7.  Jaundice.

8.  Rash or pustules not present on discharge.

9.  Concerns.

BIBLIOGRAPHY

Car Safety Seats: A Guide For Families 2010. American Academy of Pediatrics Healthy Children website:
http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats-Information-for-Famiies-2010.aspx
. Accessed June 2, 2011.

DeMichele AM, Ruth RA. Newborn Hearing Screening. Medscape Reference; 2010:
http://emedicine.med-scape.com/article/836646
. Accessed June 2, 2011.

Diekema DS, and Committee on Bioethics of American Academy of Pediatrics. Clinical Report: “Responding to Parental Refusals of Immunization of Children” Reaffirmed policy on May 1, 2009. American Academy of Pediatrics website:
http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;115/5/1428
. Accessed June 2, 2011.

Fouzas S, Mantagou L, Skylogianni SM, et al. (2009). Transcutaneous bilirubin levels for the first 120 postnatal hours in healthy neonates.
Pediatrics.
2009;125(1):e52-e57. Retrieved from American Academy of Pediatrics website:
http://www.pediatrics.org/cgi/content/full/125/1/e52
. Accessed June 2, 2011.

Hagan JF, Shaw JS, Duncan P. (eds).
Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents.
3rd ed. American Academy of Pediatrics; 2008:
http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html
. Accessed June 2, 2011.

March of Dimes.
National Standard for Newborn Screening is Announced.
Published May 21, 2010:
http://www.redorbit.com/news/health/1869169/national_standard_for_newborn_screening_is_announced/
. Accessed June 2, 2011.

March of Dimes. Pregnancy and Newborn: Newborn Screening Tests. 2010:
http://marchofdimes.com/pnhec/298_834.asp
. Accessed June 2, 2011.

Medoff-Cooper B, Bakewell-Sachs S, Buus-Frank ME, et al. (Near Term Advisory Panel). The AWHONN near-term infant initiative: A conceptual framework for optimizing health for near-term infants.
JOGNN: Principles and Practice.
2005;34(6):666-671.

Rauch D. Neonatal weight gain. MedlinePlus website:
http://www.nlm.nih.gov/medlineplus/ency/article/007302.htm
. Accessed June 2, 2011.

Recommended Immunization Schedule for Persons Aged 0 through 6 Years–United States 2010. Centers for Disease Control and Prevention website:
http://www.cdc.gov/vaccines/recs/acip
. Accessed June 2, 2011.

CHAPTER 7

One-Month Visit

Candace F. Zickler

I.  GENERAL IMPRESSION

A.  Parents and infant should be settling into routine and more comfortable with each other. Parent should be very attentive to the infant and have lots of questions. There should also be a sense that parent is comfortable with the infant. Parent is able to describe characteristics of infant's temperament. Mother should have someone identified that she can leave baby with for brief periods of time.

II. NUTRITION

A.  Breastfeeding is to be encouraged. Determine if baby is satisfied after feedings, how frequently baby is nursing, how long a feeding takes, and any concerns mom has about continuing nursing. Ask about plans/arrangements to return to work.

B.  Formula.

1.  Mix formula with bottled water for first month, continue to use bottled water if house is on well/unsure of water quality. Have well water tested at local health department for small fee.

2.  Store ready-to-feed and open formula bottles in refrigerator. Refrigerate no longer than 24-36 hours.

3.  Specialized formulas have similar preparation directions; read labels. Goat's milk, whole cow's milk, rice milk have inadequate amounts of vitamins and minerals.

4.  Serve formula at room temperature. Do not microwave to heat. Do not let formula sit out to warm for more than 15-20 minutes.

5.  Clean technique is sufficient for mixing formulas.

a.  Clean off cans with soap and water before opening.

b.  Use hot soapy water and bottlebrush to clean nipples and bottles or clean in dishwasher.

6.  Hold infant in upright, semi-reclined position; burp every 1-2 oz.

a.  No bottle propping.

b.  No smoking or drinking hot beverages while holding baby.

7.  One-month old infant will take 4-6 oz/feeding and 5-6 feedings/24 hours (90-120 cal/kg/day).

III. ELIMINATION

A.  Should have 1-6 yellow pasty stools/24 hours.

B.  With each feeding, breastfed infant may have softer, formed/seedy stools.

C.  Void every 1-3 hours or with each feeding.

IV. SLEEP

A.  Awake and alert for feedings, every 2-4 hours. Baby will suck vigorously for 15-20 minutes, then fall back to sleep.

B.  Babies should sleep in own cribs, not with parents, to decrease risk of smothering or injury.

C.  Babies should sleep on back or side in cribs to decrease risk of sudden infant death syndrome (SIDS).

D.  No pillows/toys that baby could get face against and smother.

V.  GROWTH AND DEVELOPMENT

A.  Growth. Weigh infant naked on infant scales. Compare weight to last visit. Calculate rate of gain since last visit. Measure length on length board and head circumference. Plot values on National Center for Health Statistics (NCHS) growth chart. Discuss your findings from the growth charts.

1.  Should gain 0.5-1 oz/day or approximately 2 lbs/month for next 4 months.

2.  Infant grows, on average, 1 in./month for first 6 months.

3.  Head circumference increases 0.5 cm/month in first year.

B.  Development. Responds to human face and follows briefly with eyes. Is attentive to sound of parent's voice.

1.  May be able to lift head off bed if on tummy.

2.  May have a smile.

3.  Has positive red reflexes bilaterally and blinks to light. Tear ducts may have tears appear; tear ducts should be patent.

4.  Assess scalp for cradle cap and diaper area for dermatitis. Review how to care for baby's skin.