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Well Care Examinations for pediatrics: growth and development of babies, children and adolescents

Well Care Examinations for pediatrics: growth and development of babies, children and adolescents . Debbie King RN, MSN FNP, PNP, APRN. Communication in primary care pediatrics . Professional interaction, sensitive yet nonjudgmental. Include parent and child.

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Well Care Examinations for pediatrics: growth and development of babies, children and adolescents

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  1. Well Care Examinations for pediatrics: growth and development of babies, children and adolescents Debbie King RN, MSN FNP, PNP, APRN

  2. Communication in primary care pediatrics • Professional interaction, sensitive yet nonjudgmental. Include parent and child. • Common courtesies count. Socialize. • Start interview with open ended questions, build rapport. Repeat important phrases. • Use close ended questions for clarification. • Limit medical jargon, be aware of body language and “guide the interview”. • Empathize and acknowledge parental concerns. • Recognize personal limitations • Summarize the interview

  3. Talking to Parents • EFFECTIVE COMMUNICATION IS THE KEY. • OBSERVE INTERACTION BETWEEN PARENT AND CHILD. • ASSESS FAMILY DYNAMICS. • ADDRESS PARENTAL CONCERNS IN A NONJUDGEMENTAL MANNER.

  4. Talking to Parents • ESTABLISHMENT OF LONG TERM RELATIONSHIPS. • PRIMARY CARE GIVERS ROLE IS MULTIDEMENSIONAL. • IMPORTANT TO ADDRESS THE NONMEDICAL AND PSYCHOSOCIAL CONCERNS OF PARENTS. • ADDRESS PARENTAL FEARS. • ALLOW OPPORTUNITY FOR QUESTIONS.

  5. Normal newborn and infant development • Influenced by biological and environmental factors. • Primitive reflexes are present from birth until 6 months. Suppression related to normal development and/or reappearance could indicate brain damage. Moro Reflex- allowing infants head to drop back. Disappears by 4 mos. Rooting Reflex and Sucking Reflex Palmer or Grasp Reflex-Disappears 3mos. Stepping Reflex-disappears 2mos. • Tonic Neck Reflex-(fencer) Disappears 3mos

  6. New Born Visits (~3 days old) • Introduction • Congratulations • Other children • Pre-natal • Due date

  7. Newborn visit • Type of delivery • Birth weight • Discharge weight and age • Hearing test • GBS status • Mother and Baby blood types

  8. Newborn visit • PKU • Hepatitis B #1 • Bilirubin –ordered stat as needed • Circumcision-research contends “reduced risk of HIV in circumcised males” • Diet • Breast/bottle

  9. New Parent Education • Provide verbal and written information • Feeding • Schedule • BF support • Positioning of the newborn • Safety • Illness

  10. New parent education • Exposure-limit visitors and outings • BM’s- vary with babies • Hick-ups- are frequent • Sneezing-normal and frequent • Congestion-off and on and is normal

  11. New parent education • Dressing/layers- do not overdress • Siblings • Car seat • Finger nails- file only for 6 weeks

  12. New parent education • Cord care- there is none • Smoking-avoid exposure • Sun-not directly, can use sun-block • Oral Needs- Gums and Pacifier-new research contends “pacifier use for all sleep periods is necessary to prevent SIDS”

  13. New parent education • Illness protocols • Office procedures with calls • When to call • Recheck schedule- varies

  14. General info • Average weight 7 lb • Average length 20-21 inches • Normal average weight loss is 10% in first 3-4 days • Normal- is to regain back to birth weight by 14 days

  15. General info • Weight doubles by 4 months • Weight triples by one year • Weight quadruples by two years • Normal weight gain is 6-8 oz per week for 6 months • Normal weight gain is 3-4 oz per week from 6-12 months • Normal weight gain 1-2 years old is 8-9 oz per month

  16. FYI • Theories are important in practice to help you know “normals” • They will be on boards (only a few pediatric theorist questions) • Should self study • Erikson • Mahler • Skinner • Maslow • Kohlberg • Piaget • Roy

  17. Breast Feeding • Breast milk or iron fortified infant formulas provides complete nutrition for infants first 4-6 months of life. • First 1-2 months, 2-3 ounces of formula or 10 minutes on each breast q 2-3 hours. • Breast milk digests 1 ½ hr, formula digests up to 4 hers. Breast-fed infants feed 8-12 times per 24 period compared to formula fed infants at 6-8 times per 24 hr period. • Mother’s milk (colostrum 7-10 days) is high in protein, immunoglobulins and secretory IgA. Allergy and infection protective. • Breast feeding is the recommended method of feeding.

  18. Exam Of Newborn - Importance of Clinical Experience • General • hydration • Skin- Color- Birth marks • If highly abnormal consider neuro consult • Head- Shape- Size • Eyes- red reflex- alignment • crossing • ENT- ear placement • If abnormal check kidneys

  19. Newborn • Mouth- palate • Chest/heart- • ~140- ?murmur • tachypnea • poor feeding • cool lower ext- ?COA • pulses • Lungs/resp- ~30-60 • Abdomen- cord • GU- Open, rectum

  20. Newborn • Musculoskeletal- hips • Tone • Neuro- (reflexes) startle, tone, grasp, rooting, sucking, gag, crying symmetry of movement

  21. 2 Week Visit • Birth weight • Weight today-should be back to BW • Age of discharge- • If this is first visit • Do all of the first visit as well • Diet • Color • Advise parents not use any medications

  22. 2 Week Visit • Circumcision • PKU • Address concerns of parents • Exam- 2 week is Repeat of New Born exam

  23. 1 Month Visit • Temperature • Height • Weight • HC • Percentiles- Know how to ‘plot’ yourself

  24. 1 Month Visit • Diet- Vitamins A,C,D for babies BF only • Startles • Lifts head holds erect • Focus • Head support

  25. 1 Month Visit • Hands fisted • Eyes- sees short distance, may cross off and on, follows to mid line, may seem to look just by or over you • Sleep-still pretty irregular • Personality- fussy vs. happy

  26. 1 Month Visit • Spitting- amounts • Sneezing/ congested • Grunting • Only sleeps, eats, and poos • Colic • May be noted around this age

  27. 1 Month Visit • Medication not to be used this early • Safety • 1 month exam • Same as New Born -Summarize Hep B #2 today -Warn- more immunizations at 2 months

  28. 2 Month Visit • Temperature • Height • Weight • HC • Percentiles- • no pattern yet

  29. 2 Month Visit • Smiles • Coos • Focus and follow • Tone- increased head control • Diet- • vitamins if breast fed • no solids

  30. 2 Month Visit • Cuddle, eye contact, play • Increase tummy time • Position • Torticollis is common problem and may be avoided in many babies • Intake amount • elimination • 2 month exam- Same as New Born • Still no medications

  31. 4 Month Visit • Temperature • Height • Weight • HC • Percentiles- 3 is a pattern

  32. 4 Month Visit • Diet- BF, formula • Laughs, ah-goo • Reaches may start to bring to mouth • May start to transfer hand to hand • Rolls- front to back • Sleep- longer at night • Intake and elimination • Still no medicines are recommended

  33. 4 Month Visit • Self Soothes • Increase tummy time • Review safety- car seats, toys • Activities- ex. Johnny Jump Up • 4 month exam- same as New Born extra focus on tone and strength encourage team work of parents Follow up on previous visits past concerns ex; constipation, not sleeping much past unmet milestones If first visit gather all info that was needed at all previous visits.

  34. Solids • Solid foods introduced at 6 months (weight twice of birth weight or 13lbs, consumption of 32oz of formula q day, frequent feeding > 8-10 times per day. • Iron fortified cereal (rice) is introduced. • Fruits and veggies within a few weeks and meats introduced at 6-9 months. • Order in not important, but only add 1-2 new foods per week. • Careful of excessive juice intake = Diarrhea and/or feeling full • 2 ounces of juice per day per the AAP. • Weaning from breast/bottle to cup 6-18 months. Homogenized milk at 12 months. Skim or 2% not before 2 years.

  35. 6 Month Visit • Temperature • Height • Weight • HC • Percentiles

  36. 6 Month Visit • Diet- start solids, so less liquids - finger foods, new research contends “that meat be included in the food package for breast-fed infants at 6 months” one new food every 3 days • Reaches, grasps, racks • Transfers hand to hand well • Sits alone or almost • Rolls both ways • Set schedule- eating, sleep

  37. 6 Month Visit • Knows name • Babbles • Encourage crawling • Vocalizes • Safety! Child proof • Teeth • Intake and elimination • May use Tylenol for pain or fever. Motrin is now approved down to six months. No other OTC meds approved

  38. 6 Month Visit • 6 month Exam -Same as all past with focus on -Strength -Standing -Socializing with provider -Add Fluoride-if on well water -Summarize -Encourage

  39. 9 Month Visit • Temperature • Height • Weight • HC • Percentiles

  40. 9 Month Visit • Diet- more table food, cup, self feed • Schedule- toddler like • Safety- add poison control • Encourage mobility- crawling • Should have started at 7 to 8 months • Pulling up • Beginning good pincer skills

  41. 9 Month Visit • Cruising • Stands alone • Responds to name • Understands no, bye • Parents may begin saying no and removing from unacceptable places, ECT • May begin to respond to one step commands

  42. 9 Month Visit • Babbles more- • Starts about 8 months mama, dada- just sounds • Same PE • Intake and elimination • Order/evaluate- HGB • Summarize • Next exam at 12 months • Advise may see increase illness with increase in mobility

  43. 12 Month Visit • Height • Weight • HC • Temperature • Percentiles (Triple BW)

  44. 12 Month Visit • Diet- all table food -except shell fish and honey -start whole milk, cup, self feed • Sleep- schedule • Continue to encourage -verbalizing, mobility, walking

  45. 12 Month Visit • Says mama and dada with meaning • 3 to 5 words • Waves • Good pincer grasp • Begins pointing • Temper tantrums • Plays games • Follows one step command • May be walking now (by 14 mo.)

  46. 12 Month Visit • Loves books and outside • Safety is more important • Car seat-24 months and 20 lbs. to face forward • Teeth-just water and tooth brush

  47. 12 Month Visit • Follows one step command • Stoops and recovers • Imitates • T.B./ lead questionnaires for exposure

  48. 12 Month Visit • 12 month exam -head to toe - More difficult -Be creative, playful -May notice hand preference soon, yet could be as late as 5 years for set handedness -testicles- should be down

  49. 12 Month Visit -hydrocele- gone -summarize this visit and growth and development since birth, seeing that areas have been covered and documented -Choose care givers carefully (baby-sitters) -Next visit 15 month and all basic vaccines will be completed except Hep A

  50. 15 Month Visit • Height • Weight • HC • Temperature • Percentile

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