Well Child Care 0-12 Months

1. Well Child Care0-12 Months Kellie Ernzen Kruger, M.D. Med-Peds Rounds August 11, 2010

2. The Systematic Approach • Aviation • Surgery • Engineering • Industrial operations • Litigation • Financial planning • Event planning • Resident to-do lists…

4. 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)

5. A Systematic Approach to Well Child Care • Diet • Elimination • Sleep • Development • Home • School • Safety • Vaccines • Anticipatory Guidance

6. 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!

7. 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?

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. Two months • Development • Follows objects past midline • Lifts head when lying on stomach • Home • Who lives at home? • Tobacco exposure • School

15. Two months • Safety • Back to sleep, rear-facing carseat • Vaccines • DTaP, IPV, HepB (Pediarix) • Hib • PCV13 • Rotavirus • Anticipatory Guidance • Tummy time • Colic • Childcare • Reflux

16. 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

17. 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

18. 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

19. 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)

20. 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

21. Six months • Safety • Mobility at home • Vaccines • DTaP, IPV, HepB (Pediarix) • Hib • PCV13 • Rotavirus • Anticipatory Guidance • Childproofing the house • Sunscreen • Water safety • Teething

22. 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

23. 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

24. Nine months • Safety • Continue rear-facing in car • Vaccines • None • Anticipatory Guidance • Childproofing the house • Water safety • Sunscreen • Teething

25. 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

26. 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

27. 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

29. What do to about… • Vitamin D supplementation? • Iron supplementation? • Fluoride supplementation?

30. Remember the Systematic Approach! • Diet • Elimination • Sleep • Development • Home • School • Safety • Vaccines • Anticipatory Guidance