Well Child Care0-12 Months

Well Child Care0-12 Months

Kellie Ernzen Kruger, M.D.

Med-Peds Rounds

August 11, 2010

Kellie Ernzen Kruger, M.D.

Med-Peds Rounds

August 11, 2010

The Systematic Approach

• Aviation• Surgery• Engineering• Industrial operations• Litigation• Financial planning• Event planning• Resident to-do lists…

Systematic Approaches in Medicine and Pediatrics

• H&Ps– CC, HPI, PMHx, PSHx, Meds, Allergies, FHx, SHx,

ROS, PE, Labs, Studies, Assessment and Plan

• Admission Orders– ADCVAANDIML

• EKG interpretation– Rate, Rhythm, Axis, Intervals, Morphology, R wave

progression, ST segment changes

• Chest xray interpretation– ABCDE (Airway, Bones, Cardiac, Diaphgrams,

Everything else)

A Systematic Approach to Well Child Care

• Diet• Elimination• Sleep• Development• Home• School• Safety• Vaccines• Anticipatory Guidance

Well Child Care in the First Year

• Hospital Follow-up• 2 weeks• 2 months• 4 months• 6 months• 9 months• 12 months

Use the same systematic approach with every visit!

Hospital Follow-up

• Diet– Breast feeding vs formula– Frequency of feeds – minimum q2-3 hrs, 15 minutes each side

or 2-3 oz at every feed– Burping at the end of each feed– Check-in about breast feeding – is mom’s milk in? If possible,

observe breastfeeding

• Elimination– Frequency of wet diapers – minimum 5-6 per day– Bowel movements – minimum 3-4 per day

• Sleep– Waking at least every 4 hours to feed– Is mom sleeping when baby sleeps?– Does the baby sleep in his own crib/bassinette?

Hospital Follow-up

• Development– Newborn reflexes (Moro, rooting, suck, palmar

grasp)

• Home– Who else lives at home? Other children?

How are they adjusting to the new baby?– Tobacco exposure

• School

Hospital Follow-up

• Safety– Back to sleep, nothing in the crib, rear-facing carseat

• Vaccines• Anticipatory Guidance

– Jaundice– Breastfeeding support– Maternal depression screening– Fever precautions/avoiding crowds (relatives, church,

etc)– “Normal” newborn things – sneezing, hiccupping

Two weeks

• Diet– Breast feeding vs formula– Frequency of feeds – minimum q2-3 hrs, 15 minutes

each side or 2-3 oz at every feed– Burping at the end of each feed– If possible, observe feeding (breast or bottle)

• Elimination– Frequency of wet diapers – minimum 5-6 per day– Bowel movements – minimum 3-4 per day

• Sleep– Waking at least every 4 hours to feed– Is mom sleeping when baby sleeps?– Average 16-20 hours sleep per day

Two weeks

• Development– Follows objects to midline

• Home– Who else lives at home? Other children?

How are they adjusting to the new baby?– Tobacco exposure

• School

Two weeks

• Safety– Back to sleep, nothing in the crib, rear-facing carseat

• Vaccines

• Anticipatory Guidance– Weight check– Colic– Maternal depression screening– Fever precautions/avoiding crowds – “Normal” newborn things – sneezing, hiccupping

Two months

• Diet– Breast feeding vs formula– Frequency of feeds – q3-4 hrs, 15 minutes each side

or 3-4 oz at every feed– Burping in the middle or at the end of each feed

• Elimination– Frequency of wet diapers – minimum 5-6 per day– Bowel movements – usually 2-3 per day

• Sleep– Average 15 hours sleep/day (usually 10 hrs at night)– May sleep 5-6 hours at a time at night, with 2-3 naps

during the day

Two months

• Development– Follows objects past midline– Lifts head when lying on stomach

• Home– Who lives at home?– Tobacco exposure

• School

Two months

• Safety– Back to sleep, rear-facing carseat

• Vaccines– DTaP, IPV, HepB (Pediarix)– Hib– PCV13– Rotavirus

• Anticipatory Guidance– Tummy time– Colic– Childcare– Reflux

Four Months

• Diet– Breastfeeding/bottle feeding q3-4 hrs– No longer needs a nighttime feeding– Solid foods – one new food per week

• Begin with cereal – rice, oatmeal, mixed grain

• Elimination– Stooling – can be 3x/day to once every 3 days, after

starting solid foods

• Sleep– Average 14-16 hours sleep/day, with 2-3 naps– Nighttime sleep routine, e.g. bathtime, reading,

rocking, singing, etc

Four months

• Development– Reach for objects– Push up onto his hands when lying on his stomach– Roll from stomach to back– Vocalize “ah-goo” and other vowel-consonant combos

• Home– Who lives at home?– Tobacco exposure

• School

Four months

• Safety– Back to sleep, rear-facing carseat

• Vaccines– DTaP, IPV, HepB (Pediarix)– Hib– PCV13– Rotavirus

• Anticipatory Guidance– Rolling– Introduction of solid foods– Stimulation – toys to develop motor skills, reading

books

Six Months

• Diet– Solid foods – one new food per week

• Cereal, then vegetables, then fruits, then meats• Work up to eating solids 3 times/day, mimicking mealtimes• Continue breastfeeding/formula feeding after solids

• Elimination• Sleep

– Cold turkey– Ferber method– Anticipate need for sleep – avoid overtiredness– Be consistent and give it time to work (at least 2 wks)

Six months

• Development– Sit with/without support– Turn in the direction of parents’ voice– Roll from back to stomach– Rake objects into a fist

• Home– Bathing - change to tub, if able to sit unassisted

• School

Six months

• Safety– Mobility at home

• Vaccines– DTaP, IPV, HepB (Pediarix)– Hib– PCV13– Rotavirus

• Anticipatory Guidance– Childproofing the house– Sunscreen– Water safety– Teething

Nine Months

• Diet– Three meals a day, with snacks in between

• Continue breastfeeding/formula feeding after solids• Be persistent when it comes to introducing new foods – may

need 15-20 attempts

– Continue to introduce finger foods– Introduce a sippy cup

• Elimination• Sleep

– Transition from 3 naps to 2 naps during the day– Sleep uninterrupted overnight– Consistent nighttime routine

Nine months

• Development– Crawl/creep along the floor– Stand with assistance– Look for dropped objects– Begin using pincer grasp– Babble “mama” and “dada”, though indiscriminately– Separation anxiety– Ages and Stages Developmental Screen

• Home– Childproofing the house– Teeth brushing

• School

Nine months

• Safety– Continue rear-facing in car

• Vaccines– None

• Anticipatory Guidance– Childproofing the house– Water safety– Sunscreen– Teething

Twelve Months

• Diet– Three meals a day, with snacks in between– Continue with finger foods– Introduce cow’s milk in a cup, to help wean the bottle– Continue breastfeeding as desired

• Elimination• Sleep

– Average sleep 13-14 hours/day, with 1 or 2 daytime naps

– Sleep uninterrupted overnight– Consistent nighttime routine

Twelve months

• Development– Cruise along furniture– Stand alone– Drink from a sippy cup– Say “mama” or “dada” discriminately– Wave bye-bye

• Home– Changes in family members/caregivers

• School– Social interactions – play groups, trips to the park for

children not in daycare or school

Twelve months• Safety

– Okay to face forward in the car, at 12 months and minimum 20 lbs (still safer to face backwards)

• Vaccines– MMR– VZV– Hep A– Hib*– PCV13*

• Anticipatory Guidance– Water safety– Sunscreen– Discipline and setting limits– Anemia, Lead, TB screening when appropriate

What do to about…

• Vitamin D supplementation?

• Iron supplementation?

• Fluoride supplementation?

Remember the Systematic Approach!

• Diet• Elimination• Sleep• Development• Home• School• Safety• Vaccines• Anticipatory Guidance