GUIDELINES FOR HEALTH SUPERVISION

GUIDELINES FOR HEALTH SUPERVISION SUZANNE LEFEVRE, MD

Resources • Bright Futures Guidelines for Health Supervision 3rd Edition, 2008 Initiative of the Federal Maternal and Child Health Bureau (HRSA) Goal is to improve the quality of health services for children through health promotion and disease prevention What is Bright Futures? “Set of principles, strategies, and tools that are theory based, evidence driven, and systems oriented, that can be used to improve the health and well-being of all children through culturally appropriate interventions that address their health promotion needs at the family, clinical practice, community, health system and policy levels”.

Bright Futures • Core competencies • Building Effective Partnerships • Fostering Family-Centered Communication • Promoting Health and Preventing Illness • Managing Time for Health Promotion • Educating Families Through Teachable Moments • Advocating for Children, Families and Communities

Bright Futures • Promoting: • Family support • Child Development • Mental Health • Healthy Weight • Healthy Nutrition • Physical Activity • Oral Health • Healthy Sexual Development and Sexuality • Community Relationships and Resources

VISIT SCHEDULE • PRENATAL • NEWBORN • 1 WEEK • 1 MONTH • 2 MONTH • 4 MONTH • 6 MONTH • 9 MONTH • 12 MONTH • 15 MONTH • 18 MONTH • 2 YEAR • 3 YEAR • 4 YEAR • 5 YEAR • 6-7 YEAR • 8-9 YEAR • 10-11 YEAR • ADOLESCENT

VISIT COMPONENTS • INTERVAL HISTORY AND OBSERVATION • NUTRITION • ELIMINATION • SLEEP • BEHAVIOR/DEVELOPMENT/SCHOOL PERFORMANCE • PHYSICAL EXAMINATION • SCREENINGS • IMMUNIZATIONS • ANTICIPATORY GUIDANCE AND SAFETY

FIRST WEEK VISIT • BIRTH HISTORY/OBSERVATION • General questions: Do you have any concerns about the baby? How have you been feeling? How are other family members adjusting to the new baby? • Ask about prenatal, labor and deliver, neonatal course in the hospital • Notice how family members interact Who asks most of the questions? Are both parents present? Do the parents appear happy, depressed, fatigued or overwhelmed?

FIRST WEEK VISIT • Prenatal, labor and delivery and neonatal course • Did the mother receive prenatal care? • Were all prenatal studies normal? • Does either parent have a history of STD’s • Does either parent have a history of alcohol, tobacco or illicit drug use? • Did the mother have any complications during pregnancy? • Were there any indications of a complicated delivery? • Is the mother breastfeeding? • Does the neonate have any siblings? • Is anyone available to help with the new baby or siblings?

FIRST WEEK VISIT • Nutrition • Is your baby breast fed or formula fed? • How much and how often does your baby feed? • Anticipatory Guidance Exclusive breastfeeding for 4 to 6 months is ideal Iron-fortified formula as alternative No need for extra water Develop feeding routine (volume and number of feeds) Breast feeding on demand Formula feeds 2 to 3 ounces every 2 to 3 hours Preparation and storage of formula and breast milk Don’t prop the bottle

FIRST WEEK VISIT • Elimination • How many diapers does your baby wet? • Does your baby have a bowel movement every day? • Anticipatory Guidance Breast fed babies have frequent loose stools that decrease over next few weeks Most babies have 5 to 6 wet diapers per day and 3 to 4 stools per day • Sleep • How many hours does your baby sleep at one time? • Does your baby wake up for feeds? • Anticipatory Guidance Sleep location (crib, bassinette, bed?) Crib slats should be less than 2 3/8 inches apart, no soft bedding, no toys Sleep position on back

FIRST WEEK VISIT • Development Do you have concerns about your babies development? • Social-emotional Able to sustain periods of wakefulness for feedings Will gradually have longer periods of sleep (4 to 5 hours at night) • Communication Turns and calms to parent’s voice Communicate needs through his behaviors Undifferentiated cry • Cognitive Is able to fix briefly on faces and objects Follows face to midline • Physical development (gross or fine motor) Shows strong primitive reflexes Is able to lift head briefly when in the prone position

FIRST WEEK VISIT • Screenings Metabolic Hearing : Should be done within first month of life if not immediately after birth Vision: Abnormal red reflex or prematurity with risk conditions requires ophthalmology referral • Immunizations Hepatitis B if not given • Safety Car seats should be rear facing in back seat (toll-free 866-seatcheck) Keep home and vehicle smoke-free Avoid drinking hot liquids while holding the baby Set home water temperature to less than 120 degrees F Skin care: Fragrance-free products Cord care: “air dry” Call MD if bad smell or redness develop

FIRST WEEK VISIT • New born Screening Disorders • Organic Acid Disorders • Fatty Acid Oxidation Disorders • Amino Acid Disorders • Maple Syrup Urine disease • Citrullinemia • Argininosuccinic acidemia • Tyrosinemia type 1 • Homocystinuria • Phenylketonuria • Hemoglobinopathies • Congenital Hypothyroidism • Congenital Adrenal Hypoplasia • Galactosemia • Cystic Fibrosis

FIRST WEEK VISIT • Physical exam • Complete exam Attention to: Measure and plot length, weight, head circumference General observation for anomalies (head, ears, palate, genitalia and rectum, back and spine) Skin: Rashes or jaundice Head: Shape, fontanel's, evidence of birth trauma Eyes: Inspection, mobility, red reflex Heart: Murmurs, femoral pulses Abdomen: Umbilical cord Musculoskeletal: Check for hip clicks Neurological: Posture, tone, activity level, symmetry of movement

FIRST WEEK VISIT • Common Physical Findings in Newborns • Skin: Milia, erythema toxicum, salmon patch, nevus flammeus, hemangiomas, mongolian spots , lanugo • Head: Cephalohematoma, caput succedaneum • Face: Swollen faces • Eyes: Swollen eyelids, subconjunctival hemorrhages • Ears: preauricular appendages/pits, folded pinnae • Nose: Flattened nose ,milia over bridge • Mouth and Throat: Epstein pearls, natal teeth, shortened frenulum • Chest: Supernumerary nipples, breast buds, galactorrhea, pectus deformities • Female Genitalia: Swollen labia, hymenal tags, vaginal discharge • Male Genitalia: Hydrocele, undescended testicle • Hips: Click • Extremities: Metatarsus adductus • Neurological Exam: Primitive reflexes: moro, grasp, rooting, stepping

FIRST MONTH VISIT • Interval History/Observation • Any problems since your last visit? Any trips to the ED? • How do the parents interact with the infant? Do they respond to infant cues? Do they have time for self and partner? • Nutrition • How is feeding going (what, how much, and how often)? • Anticipatory Guidance Continue to promote formula or breast feeding only If breast feeding: Vitamin D (400 units) beginning at 2 wks to 2 months If formula fed: Average 24 to 27 (not more than 32) ounces. Feed 2 to 3 ounces q 2 to 3 hours. • Elimination • Number of bowel movements usually decreases • Sleep • Back to sleep • Tummy time when awake • Continues to wake for feeds • Sleeps 4 to 5 hours at night

FIRST MONTH VISIT • Development/Behavior • Social-emotional Is responsive to calming actions when upset • Communication Is able to follow parent with eyes Recognizes parent voices • Cognitive Has started to smile • Physical (gross or fine motor) Is able to lift head when on tummy • Screening • Metabolic • Hearing • Vision

FIRST MONTH VISIT • Physical Exam • Complete exam • Attention to Measure and plot height, weight, and head circumference Head: note positional skull deformities Eyes: note red reflex, eye color and clarity Heart: murmurs and femoral pulses Abdomen: healing of umbilicus, masses Musculoskeletal: check for hip clicks Neurologic: tone , response to auditory and visual stimuli

2 MONTH VISIT • Interval History/Behavioral Observations • How are you and the baby doing? Any post-partum check-up issues? • Do the parents support each other or show signs of disagreement? • How are sibling relationships? • Take note of potential parent/child separation with return to work • Nutrition • How is feeding going? • Anticipatory Guidance Same as 1 month: Formula feeds 24-32 ounces per day, 2-3 ounces q 2-3 hours but may increase to 3 to 4 ounces every 3 to 4 hours between 2 and 4 months Plan for pumping/storage if needed • Elimination • Ask about frequency of wet diapers and bowel movements • Sleep • Does the baby have a protected sleeping environment? • Awake and alert for longer stretches

2 MONTH VISIT • Development/Behavior • Social-emotional Attempts to look at parent Smiles Is able to console and comfort self (brings hand to midline and mouth) • Communication Begins to demonstrate differentiated cry (hunger, fatigue, pain) Coos Has clearer behaviors that indicate need for sleep, food, play, comfort • Cognitive Indicates boredom (crying, fussiness) when no changes in activity occur • Physical development (gross motor or fine motor) Is able to hold up head and begins to push up in prone position Has consistent head control Shows symmetrical movements of head, arms and legs Shows diminishing newborn reflexes Able to track past midline

2 MONTH VISIT • Physical exam • Perform complete exam • Attention to: Measure and plot: length, weight and head circumference Skin: rashes, bruising Head: palpate fontanel's Eyes: inspect eyes/eyelids, RR, ocular mobility Heart: murmurs, femoral pulses Musculoskeletal: inspect for torticolis, hip click Neurologic: tone, strength, symmetry of movement • Immunizations • Rota, DTaP, Hib, PCV, IPV, Hep B

2 MONTH VISIT • Safety • Car seats • Smoke-free environment • Water temperature (less than 120 degrees) • Avoid toys with strings, loops, cords and bracelets • Keep hand on baby when changing diaper/clothes • Don’t leave baby alone in tub or high places • Keep small objects, plastic bags away from baby

4 MONTH VISIT • Interval History/Observation • Any visits to the emergency department since your last visit? • What do you enjoy most about your baby? What are the challenges? • Do the parents provide comfort when infant cries? • Nutrition (Anticipatory Guidance) • Congratulate the mom that continues to breastfeed! • Exclusive BF for 4 to 6 months is ideal. • Usual amount of formula is 30-32 ounces per day. 4 ounces q 3-4 hours. • Discuss feeding success with parents, i.e., the growth chart. • Between 4 and 6 months baby will be ready to start solid foods. May introduce rice cereal. • Be sure to ask about any herbal supplements, tea’s, etc. given to baby. • Council parents on hunger and satiation cues to ovoid overfeeding.

4 MONTH VISIT • Nutrition • Factors that indicate solid food readiness • Current weight twice birth weight (13lbs) • Consumption of more than 32 ounces of milk • Frequent feeding (more than 8 to 10 times per day) • Persistent dissatisfaction due to hunger • Solids may be added between 4 and 6 months usually rice cereal first • Rice cereal contains no gluten • Mix one ounce of cereal with 2 ounces of liquid (formula, breast milk, water) • Mixture is thin but may be thickened over next few months to consistency of mustard • First stage foods (pureed veggies and fruits) for babies ages 5 to 6 months contain no milk, eggs, citrus or wheat • Second stage foods are for 6 to 9 month old infants • Second stage foods contain mixed veggies, mixed fruits or meat dinner. • Third stage foods are for infants 9 to 10 months as these babies can sit well without support, have some teeth and have begun to self-feed.

4 MONTH VISIT • Elimination (Anticipatory Guidance) • Ask about number of bowel movements, i.e., frequency and consistency. • Counsel parents on constipation • Sleep (Anticipatory Guidance) • Baby should be getting at least 5 hours of uninterrupted sleep. • Put baby to bed awake but drowsy and continue “back to sleep”

4 MONTH VISIT • Development and behavior • Social-emotional: Smiles spontaneously Elicits social interactions Shows solidified self-consolation skills • Communication: Cries in differentiated manner for hunger, fatigue and pain Babbles more expressively and spontaneously • Cognitive: Responds to affection and changes in environment Indicates pleasure and displeasure • Physical development (motor):gross motor and fine Pushes chest to elbows Has good head control Shows symmetrical movements of arms and legs Begins to roll and reach for objects

4 MONTH VISIT • Complete Physical Exam • Screening • Vision • Hearing • Anemia Pre-term and low birth weight infants and those on low iron- fortified formula • Immunizations • Rota, DTaP, Hib, PCV 13, IPV

4 MONTH VISIT • Anticipatory guidance and safety • Oral Health Maternal oral health care impacts baby. Avoid sharing spoons or cleaning pacifier with mouth. Teething may start just prior to 6 month visit. Cold teething ring may ease discomfort. Avoid bottle in bed, propping or “grazing”. • Use quiet playtime by reading, singing and active playtime with tummy time. • Provide safe opportunities to explore • Spend time with your other children • Make quality child care arrangements • Safety Avoid burn risks (water temperature and hot liquids) Car seats, smoke-free environment, toys with strings, loops, bracelets The kitchen is the most dangerous place in the house. If unable to provide full attention keep baby in playpen, crib or stationary activity center while busy Check for sources of lead in home

6 MONTH VISIT • Interval History and Observation • Any concerns since your last visit? • Is your child in daycare? • How does the infant respond to parents? • Nutrition (Anticipatory Guidance) • Continue breast feeding if desired • Recognize slowing of growth rate • Introduce solids, single-ingredient one at a time. Provide iron rich foods • Repeat exposure enhances acceptance of new foods. It may take 10 to 15 experiences before a new food is accepted • Begin using cup • Limit juice to 2-4 ounces per day • Elimination (Anticipatory Guidance) • Stools may change with introduction of new foods

6 MONTH VISIT

6 MONTH VISIT • Sleep • Remember to reinforce idea of safe sleeping, i.e., cribs or protected area in bed • Screening • Vision • Hearing • Lead risk assessment • Immunizations • Rota, DTaP, Hib, PCV 13, • Complete Physical Exam

6 MONTH VISIT • Development/Behavior • Social-emotional: Is socially interactive with the parent Recognizes family members versus strangers • Communication Babbles and enjoys vocal turn taking Is beginning to recognize own name • Cognitive Uses visual and oral exploration for learning • Physical development (gross and fine motor) Rolling over front to back and back to front Maintain sitting position Will move from sitting position to crawling position Transfers object from one hand to another

6 MONTH VISIT • Anticipatory Guidance and Safety • Oral Health Assess fluoride source and supplement if water source contains less than 0.3ppm. New Orleans has 0.2 to 1.1ppm (East Bank) and 0.3 to 1.4ppm (West Bank) Brush teeth with soft brush or cloth and water. Avoid bottle in bed, propping or “grazing” • Continue rear facing car seat until 2 years • Home safety check (stair gates, barriers around heaters, cleaning products) • Have Poison Control Center number available: 1-800-222-1222 • Don’t use infant walkers • Limit finger foods to soft bits to prevent choking

9 MONTH VISIT • Interval History/Observation • Any concerns since your last visit? What do you enjoy most about your baby? What are the challenges? • Observe whether parents stimulate the infant with language and play • Do the parents respond to their infant’s autonomy within a safe environment? • Are the parents developmental expectations appropriate? • Nutrition • Gradually increase table foods, ensure variety and textures • Provide 3 meals and 2 to 3 snacks per day • Encourage use of cup • Elimination • Continue to ask about stool frequency and consistency Sleep • Promote good sleep hygiene by maintaining nightly routine • Baby may still take 2 naps per day

9 MONTH VISIT • Development/Behavior • Social-emotional Has developed apprehension with strangers Seeks parent for play, comfort and rescue • Communication Uses variety of repetitive consonants and vowel sounds Starts to point out objects “Mama, Dada” non-specific • Cognitive Object permanence Learns interactive games such as “peek-a-boo” Looks at books and explores the environment, physically and visually • Physical development (gross and fine motor) Rapidly expanding motor skills: crawls, gets to sitting position, begins pulling to a stand, pincer grasp.

9 MONTH VISIT • Immunizations: none if up to date • Complete Physical Exam • Screening • Structured developmental screen (ASQ) • Oral health • Vision • Hearing • Lead risk assessment

9 MONTH VISIT • Anticipatory Guidance: • Be sensitive to separation anxiety and temperament • Avoid TV, videos and computers • Play cause and effect with toys, talk/sing/read together • Keep consistent daily routines • Discipline: Teach your child what behaviors you expect. Use consistent positive discipline Set an example of the behavior you expect Describe the desired behavior as often as possible: “time to sit” rather than “don’t stand” Limit “no” to the most important issues

GUIDELINES FOR HEALTH SUPERVISION