adoption - is my baby fine doc
TRANSCRIPT
Assessing a newborn infant is like looking at an iceberg.
Only the grossest of abnormalities are apparent immediately. Some problems can be resolved by careful examination and by investigations .
evaluation Checklist Physical and neurologic examination
Medical and social history
Vision and hearing screening
Laboratory analysis of complete blood count,
chemistries
serology screening for human immunodeficiency virus, hepatitis B and C, and syphilis
Genetic screening for cystic fibrosis, Fragile X and Down syndromes
metabolic screening
TsH
Evaluation
A comprehensive medical evaluation
thorough review of the medical history, including
an assessment of health risks
a Neurological assessment and
a complete , unclothed physical
examination
comprehensive medical evaluation
not necessary during only one medical visit.
complete the assessment of the Baby’ history
Review laboratory findings
Referrals
Subsequent evaluations
One of the greatest indicators of the wellness of a newborn is the general observation or gestalt that a clinician obtains by simplywatching a baby before the start of a physical exam.
Components of the General Physical Examination
A review of the medical history including:
family history, maternal, antenatal and perinatalhistory,
infant, fetal and neonatal history
including any previously plotted birth-weight and head circumference
A review of parental concerns
Feeding
Ensure relevant information is available to healthcare professionals
History Of particular importance are
histories of the natural parents in order to assess possible genetic disorders and
information relating to the quality of the mother's pregnancy
assessment of history
Prenatal blood and urine test results of mother
○ Exposure to medications, illegal substances, alcohol, tobacco
○ Gestational age, birth weight, length, head size; Apgarscores
○ Prenatal concerns, neonatal complications
○ Newborn hearing screening results
○ newborn metabolic screening
Family history
○ Vision, hearing deficits
○ Genetic diseases
○ Concerns related to H/o eg, sickle cell anemia, thalassemia, Tay Sachs disease, lactose intolerance
○ Mental health diagnoses
Components of the General Physical Examination
Examine fontanelle(s), face, nose, mouth including palate, ears, neck and general symmetry of head, vault, sutures, fontanelles and facial features
Check eyes – opacities and ‘red reflex’
Examine the neck and clavicles, limbs, hands, feet and digits, assessing proportions and symmetry
Cardiovascular system – heart rate, rhythm and sounds, murmurs and femoral pulse volume
Components of the General Physical Examination
Initial Communication Give relevant information to parents before the
examination together with an opportunity to discuss the forthcoming screens
Whether the baby has passed meconium and urine (and the nature of the urine stream in a boy)
Observe the baby’s appearance including colour, breathing, behaviour, activity and posture
Components of the General Physical Examination
Respiratory system – effort rate and lung sounds
Abdomen – shape and palpate to identify any organomegaly. Check condition of the umbilical cord
Genitalia and anus. Check anus for patency. Check genitalia for form and undescended testicles in males
Spine – inspect and palpate bony structures and integrity of skin
Components of the General Physical Examination
Skin – note the colour and texture of the skin as well as any birthmarks or rashes
Central nervous system – observe tone, behaviour, movements, and posture and elicit newborn reflexes only if concerned
Hips – check symmetry of the limbs and skin folds. Perform Barlow and Ortolani’s manoeuvres
Cry – note sound of baby’s cry
Measurement of weight and head circumference
Head Size pay careful attention to the size of a child's head.
The head circumference is the most important measurement to follow in the pre adoption evaluation.
This measurement is the most accurate reflection of brain growth during the first years of life.
A small head (microcephaly) may suggest malnutrition, fetal alcohol exposure, or a birth defect, either genetic or resulting from the birth process.
Genetic Testing
Because the primary justification for genetic testing
of any child is a timely medical benefit to the child,
genetic testing of newborns and children in the
adoption process should be limited to testing for
conditions that manifest themselves during
childhood or for which preventive measures or
therapies may be undertaken during childhood.
Genetic Testing
In the adoption process, newborns and children should not be tested for the purpose of detecting genetic variations of or predispositions to physical, mental, or behavioral traits within the normal range.
timely medical benefit to the child should be the primary justification
If the medical or psychosocial benefits of a genetic test will not accrue until adulthood, as in the case of carrier status or adult-onset diseases, genetic testing generally
should be deferred.
Imp Considerations
Some parents expect the guarantee of a “perfect child.”
not to create a “vulnerable Child”
not the pediatrician’s role to judge the advisability of a proposed adoption
apprised clearly and honestly of any special health needs detected now or anticipated for the future.
Imp Considerations
the pediatrician should resist unreasonable
demands
empathize with the parents’ anxieties and concerns.
The welfare of children should be the first concern in the practice .
Adoptive Parents’ Interests
the best interest of the child has been and continues to be the legal benchmark of the adoption process
laws also seek to protect the interests of the adoptive parents and the birth Parents
Distinguish Preventive and therapeutic medical decisions from predictive testing.
Disclose fully child’s medical background before adoption
predictive testing goes well beyond this standard and is neither advisable nor necessary
Pediatrician’ Dilemma
The mere threat of litigation may cause some Docs to require testing without a clear understanding of their duties.
As the availability of tests increases, this pressure to test based on a fear of litigation can be expected to increase.
Docs are not guarantors of the health of the children.
They can only guarantee that the assessment & information in their possession is disclosed
Imp : eye & ear
Hearing
○ Validate newborn screening when available
○ Screen all children if possible, particularly those with risk factors for hearing loss as well as developmental (speech) delays .
• Vision
○ Eye examination as appropriate for age
○ Funduscopic examination for children with birth wt <1500
Full-term newborns with appropriate growth parameters have the best chance for normal growth and development in the future.
Immunization issues written documentation for immunizations given
? vaccine potency, storage and handling, age when given and reliability of accurate records.
two alternatives to this problem.
- Either serologic testing may be done to determine whether protective antibody levels are present or
- the child may be re-immunized.
Laboratory tests
a crucial part of the initial medical evaluation.
ensure that the child is free of diseases that could have an adverse affect on long-term health
HIV Testing a positive virological test at 6 weeks for HIV or its
components
usually by HIV-DNA PCR
The diagnosis should be confirmed by a second test on a separate sample should be repeated at the earliest
Positive antibody testing is not recommended for definitive or confirmatory diagnosis of HIV infection in children until 18 months of age
Laboratory tests
reassuring when test results are normal,
convey to parents ( that we do not know much ) about the quality control standards
Consider timing of the laboratory tests
Potential Risk factors
Prematurity
Medical and developmental risks depend on gestational age/birth weight
AND complications in the nursery …
Major and minor (but functionally important) outcomes common
But long term adult outcomes may be good
Prematurity and Low Birthweight
Increased risk of:
- cerebral palsy
- vision and hearing deficits
- learning disabilities
- ADHD
- Asthma
- Feeding problems
Look Specially for
Congenital Heart
Cleft Lip and Palate
Limb deficiencies
Genetic Syndromes
Hip Dyslplasia
Specific Concerns or Diagnoses to Discuss With Families (? Gray Areas)
Family history of mental illness or mental retardation
Antenatal drug or alcohol exposure
Prematurity
Low birthweight
Hepatitis B/C
Maternal syphilis
Developmental dysplasia of the hip
Increased muscle tone
All the conditions may not be manifest at birth
At six weeks most congenital heart lesions will have become apparent and
by three months a reasonable assessment of the infant’ neurological status can be made
Remember Usually, the features that may make a normal
newborn look strange are temporary.
In the eyes of the adoring parent, every infant looks like “the perfect baby” anyway.