Well Baby Care

CFPC 99 Topics ReviewRyan Kelly

June 16, 2015

CFPC Objectives for Well Baby Care1. Measure and chart growth parameters, including head

circumference, at each assessment; examine appropriate systems at appropriate ages, with the use of an evidence-based pediatric flow sheet such as the Rourke Baby Record.

2. Modify the routine immunization schedule in those patients who require it (e.g., those who are immunocompromised, those who have allergies).

3. Anticipate and advise on breast-feeding issues (e.g., weaning, returning to work, sleep patterns) beyond the newborn period to promote breast-feeding for as long as it is desired.

4. At each assessment, provide parents with anticipatory advice on pertinent issues (e.g., feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues).

CFPC Objectives for Well Baby Care5. Ask about family adjustment to the child (e.g., sibling interaction, changing roles of

both parents, involvement of extended family).6. With parents reluctant to vaccinate their children, address the following issues so

that they can make an informed decision: - their understanding of vaccinations. - the consequences of not vaccinating (e.g., congenital rubella, death). - the safety of unvaccinated children (e.g., no Third World travel).

7. When recent innovations (e.g., new vaccines) and recommendations (e.g., infant feeding, circumcision) have conflicting, or lack defined, guidelines, discuss this information with parents in an unbiased way to help them arrive at an informed decision.

8. Even when children are growing and developing appropriately, evaluate their nutritional intake (e.g., type, quality, and quantity of foods) to prevent future problems (e.g., anemia, tooth decay), especially in at-risk populations (e.g., the socioeconomicaly disadvantaged, those with voluntarily restricted diets, those with cultural variations)

Objective 1

• Measure and chart growth parameters, including head circumference, at each assessment; examine appropriate systems at appropriate ages, with the use of an evidence-based pediatric flow sheet such as the Rourke Baby Record.

Case 1- Kermit

• Parents bring in 9 month old Kermit for WBC

• They are worried he’s not growing as much as he was before

• First time parents• You plot him on growth

curves• Normal SVD at term, no

complications, growing well previously and meeting milestones

What else do you need to know?

What else do you need to know?

• Diet– BRF/Formula Fed– Other foods being given

• Physical activity– Cruising/walking?

• Parental heights• Environment conducive to normal growth?– ie. Low SES, substance abuse, other RFs

What if this was his curve?

Stepwise approach to FTT• When faced with a child who is not growing appropriately, the

physician/nutritionist should:1. Verify the accuracy of anthropometric measurements.2. Plot the child's weight and length or height on the growth chart.3. Calculate mid-parental height to estimate the child's growth potential.4. Obtain a complete history and perform a physical examination.5. Assess caloric intake using a food diary analysed by a trained nutritionist.6. Evaluate the child's feeding history and mealtime behaviours and explore family

dynamics.7. Perform a basic workup.8. Optimize oral caloric intake when it is found to be inadequate.9. When behavioural issues interfere with nutrition, consult a psychologist, or an

occupational or speech therapist, as appropriate.10. Consider appetite stimulants only in refractory cases, and only after evaluation by

an expert in this area.11. Tube feedings are a last resort if the child has no underlying disease.

Basic Workup

• Step 1– CBC, ESR/CRP, lytes, VBG, BG, BUN, Cr, serum

protein and albumin, serum Fe, TIBC, saturation, ferritin, Ca, PO4, ALP, LFTs, Serum Ig’s, TTG w/ IgA level, TSH, urinalysis

• Step 2– Sweat Cl-, Vitamin levels, fecal elastase, bone age

• Step 3– Refer to specialist

What if this was his curve?

Macrocephaly

• The differential diagnosis includes – Hydrocephalus– Intracranial masses (including cysts and arteriovenous malformations)– Subdural fluid collections– skeletal dysplasias– megalencephaly (increased brain mass)– benign extracerebral collection of infancy(BECC)– normal familial variant.

• Should investigate whether there is a history of signs such as vomiting, lethargy, or irritability and developmental or neurologic problems in the patient or family

What if this was his curve?

Microcephaly

Congenital (Primary)• Autosomal dominant and

autosomal recessive genetic disorders

• trisomy 13, 18, and 21• various syndromes,

– including Cornelia de Lange syndrome,

– Smith-Lemli-Opitz syndrome, and

– Rett syndrome; inborn errors of metabolism;

– hypothyroidism.

Acquired • Usually due to lack of brain

development or growth.• sequelae from:

– stroke, meningitis, or encephalitis

– other infections, such as toxoplasmosis, rubella, cytomegalovirus, and herpes

– in utero teratogen exposure– hypoxic-ischemic

encephalopathy.

Resources for growth

• Canadian Pediatric Society– http://www.cps.ca/en/documents/position/child-

growth-charts– http://www.cps.ca/documents/position/toddler-fa

lling-off-the-growth-chart• Rourke Baby record– http://www.rourkebabyrecord.ca/parents/?t=6&s

=15• About kids health

Objective

2. Modify the routine immunization schedule in those patients who require it (e.g., those who are immunocompromised, those who have allergies).

Case 2- Grover

• Grover is a 15 month old boy, presenting for his well baby check

• Has not received any immunizations

• Parents come in concerned re: recent measles outbreaks; starting to question Jenny McCarthy’s Logic

• Would like him immunized

Ontario Immunization Schedule

• http://www.health.gov.on.ca/en/pro/programs/immunization/docs/immunization_schedule.pdf

Immunization schedule

• There are also specific catch-up schedules for 7-17 year olds, and adults ≥ 18 years.

Case 3- Animal

• Animal is 1 month old• There is a family history

of primary immunodeficiency disorder- agammaglobulinemia in his older sister.

• Parents wondering if it’s safe to give him next month’s shots

For full details- CIG

Vaccines and Immunodeficiency

• Rule of thumb– Immunocompromised individuals typically may

receive inactivated vaccines– Avoid Live attenuated vaccines– Consult with specialist when unsure

Case 4- Fozzy

• Fozzy is 11 months old• He has a history of visits to

CHEO ED for breathing difficulty, eczema, and a strong family history of asthma. His sister is allergic to eggs.

• Parents concerned about getting MMR next month as they heard there may be egg products in it

Case 5- Miss Piggy

• Baby Miss Piggy is 28 months old and is known to be allergic to eggs (anaphylactic).

• It’s flu season, and parents concerned re: influenza vaccine

• She’s never had it before

For full details- CIG

Objective 6

With parents reluctant to vaccinate their children, address the following issues so that they can make an informed decision: - their understanding of vaccinations. - the consequences of not vaccinating (e.g., congenital rubella, death). - the safety of unvaccinated children (e.g., no Third World travel).

Dr. Young’s Tip

• Much like individuals who abuse substances, parents don’t necessarily respond well to lectures/information on vaccine safety

• Often helpful to start by saying– “It’s obvious that you’re great parents- this child is clearly loved”…”It’s very clear that you want what’s best for your child and you have questions about immunization”…”Tell me your concerns”.– This helps lower parents defenses and opens up the

conversation

Educate yourself

• Canadian Immunization Guide provides wealth of immunization knowledge.– Part 1, pp. 23-30

• Dense amounts of information, but available when needed.

• Some commonly quoted concerns addressed in following slides

There’s SO MANY vaccines!

• “Isn’t it bad for my child to get vaccinated against SEVEN things at once!!”

There’s SO MANY vaccines!

• “Isn’t it bad for my child to get vaccinated against SEVEN things at once!!”– NO!– Immune system can fight off as many as 10,000

antigens at the same time, seven more is not a huge deal for it

Vaccine Additives

• “What about all of the other stuff in vaccines- how do we know it’s safe?”

Vaccine Safety

• Vaccines may contain additional substances to ensure effectiveness and safety – these substances are safe.

• Vaccines do not contain anti-freeze, despite allegations by some opposed to immunisation.

Thimerosal

• contains a minute amount of one form of mercury which does not accumulate in the body as other forms of mercury can. Current routine childhood vaccines in Canada do not contain thimerosal (with the exception of certain influenza and hepatitis B vaccines).

Adjuvants

• Adjuvants, (ie. aluminum salts and squalene)– May be added to strengthen the immune

response to the vaccine. – “Without an adjuvant, people might require more

frequent or higher doses of vaccines to be protected.”

Adjuvants

• Aluminum is found in air, food and water and is present in breast milk and infant formula in similar amounts as in vaccines. Hundreds of millions of people have been safely vaccinated with aluminum-containing vaccines.

• Squalene is a naturally occurring substance often found in plants, animals and humans, as well as foods and cosmetics. It is a compound produced by the liver and circulates throughout the bloodstream.

Vaccine Additives

• Additives, such as gelatin, human serum albumin or bovine reagents, are added to vaccines to help vaccines remain effective while being stored.

Vaccine Additives

• Gelatin in vaccines very rarely causes severe hypersensitivity reactions (approximately 1 case per 2 million doses). Individuals with a history of immediate allergic reactions to foods containing gelatin or who have had an anaphylactic reaction to any of the products containing gelatin should be referred to an allergist prior to vaccination.

Vaccine Additives

• Human serum albumin: there is an extremely small theoretical risk of infectious agents being present in products made from human blood. However, steps in the manufacturing process of both human albumin and human albumin-containing vaccines eliminate the risk of transmission of these agents. There have been no documented cases of vaccine-related transmission of infectious agents by human serum albumin.

Vaccine Additives

• In Canada, the bovine-derived reagents added to vaccines included in the routine immunization schedule are manufactured from animals known to be free of bovine spongiform encephalopathy. The risk of transmitting variant Creutzfeld Jakob disease from vaccines containing bovine-derived material is theoretical, estimated to be 1 in 40 billion or less.

Vaccine Additives

• Substances, such as formaldehyde, antibiotics, egg proteins or yeast proteins, may be needed for the vaccine manufacturing process. – Formaldehyde may be used to kill or weaken the virus or

bacterium used to make a vaccine and is removed during the manufacturing process. Any trace amounts that may remain in the vaccine are safe. Formaldehyde is produced naturally in the body and helps with metabolism. There is approximately ten times the amount of formaldehyde in an infant’s body at any time than there is in a vaccine.

Vaccine Additives

– Antibiotics are used in some vaccines to prevent bacterial contamination during the manufacturing process. The types of antibiotics that are most likely to cause immediate hypersensitivity reactions (such as penicillin) are not contained in vaccines.

– Egg proteins may be used for the growth of viruses used in some vaccines. Most of the egg protein is removed in the manufacturing process but very small amounts may remain in the final product. Refer to Anaphylactic Hypersensitivity to Egg and Egg-Related Antigens in Part 2 for additional information.

Vaccine Additives

– Yeast protein is used in the manufacture of some vaccines. Hypersensitivity to yeast is very rare and a personal history of yeast allergy is not generally reliable.

– Vaccines do not contain cells from aborted fetuses or other human cells.

– Human cell lines are used in the early stages of production of some vaccines; however, all cells are removed during purification of the vaccine.

Vaccines and Autism

• “Vaccines cause autism”– No they don’t

Objective 3 and Objective 8

• Anticipate and advise on breast-feeding issues (e.g., weaning, returning to work, sleep patterns) beyond the newborn period to promote breast-feeding for as long as it is desired.

• Even when children are growing and developing appropriately, evaluate their nutritional intake (e.g., type, quality, and quantity of foods) to prevent future problems (e.g., anemia, tooth decay), especially in at-risk populations (e.g., the socioeconomicaly disadvantaged, those with voluntarily restricted diets, those with cultural variations)

Feeding/breastfeeding

• Breast vs formula– How much?– How often?

• Introducing solids– Knowing signs of readiness– Textures?!

• What about potential allergens?

How much, how often?

Markers of successful breastfeeding

• ≤ 7% weight loss in first few days after birth• Return to birth weight by at least 2 weeks• 20-30g per day weight gain in 1st 3 months• Lactation established by 4 days after birth• ≥ 8 breastfeeding events in a day• Baby latching easily• 3-6 stools/day and 4-6 voids/day by 5-7 days

old

Introducing Solids

Changing textures

Case 6- Adult Miss Piggy

• New mother- very anxious, volatile personality. Stressful relationship with partner.

• Newborn infant- you are seeing at the hospital

• She is attempting breastfeeding, but lacks confidence in her ability to breastfeed

Case 6- Adult Miss Piggy

• Advice? Resources?– Lactation consultants in house at hospital– http://www.caringforkids.cps.ca/handouts/breastf

eeding– http://www.lllc.ca/Information-sheets– http://www.lllc.ca/faq-page– Breastfeeding Solutions- App available with

guidance on a number of breastfeeding topics

My limited experience

• Often those who do not continue to breastfeed do so because of pain and latching problems

• Important to get to these moms before they quit- discuss with every newborn visit

• Important to discuss prior to delivery! Anticipatory guidance key!

Case 7- Gonzo

• 18 month old boy• Mother interested in

weaning from breastfeeding, wondering when the right time is

Case 7- Gonzo

• Advice? Resources?• CPS Position Paper

– Support exclusive breastfeeding, with vitamin D supplementation, for the first six months of life.

– Encourage continued breastfeeding for up to two years and beyond while providing appropriate nutritional guidance.

– Advise mothers to introduce iron-fortified foods in the form of meat, fish or iron-fortified cereals as first foods, to avoid iron deficiency.

– Advise slow, progressive, natural weaning whenever possible.– Inform and support breastfeeding mothers while ensuring adequate

nutrition for their babies, regardless of the timing of weaning.

Case 7- Gonzo

• Advice? Resources?– http://www.caringforkids.cps.ca/handouts/weani

ng_breastfeeding– http://www.cps.ca/en/documents/position/weani

ng-from-the-breast– Breastfeeding Solutions- App available with

guidance on a number of breastfeeding topics

Case 8- Rowlf

• Mother was previously on antidepressants. She stopped them during pregnancy

• She’s interested in going back on them, but concerned re: breast feeding

Case 8- Rowlf

• Advice? Resources?– Motherrisk.org

• ``At present, there is little evidence that exposure to antidepressants through breast milk has any serious adverse effects in infants; however, long-term neurodevelopmental effects have not been adequately studied. There are many benefits of treating postpartum depression and advantages of breastfeeding, for both the mother and the infant. Therefore, if maternal depression necessitates treatment with pharmacotherapy, then breast-feeding need not be avoided, and the antidepressant that would be most effective for the mother should be considered.``

Feeding/Breastfeeding

• http://www.caringforkids.cps.ca/handouts/feeding_your_baby_in_the_first_year

• http://www.rourkebabyrecord.ca• La Leche League Canada• Motherrisk.org• Breastfeeding Solutions- App available with

guidance on a number of breastfeeding topics

Objective 4

• At each assessment, provide parents with anticipatory advice on pertinent issues (e.g., feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues).

Objective 4

• Many of the issues of Objective 4 answered throughout the presentation and provided in resources

• Using Rourke record helps ensure issues surrounding feeding, safety discussed

• Developmental tools such as Nipissing helpful to ensure child meeting Developmental milestones

Case 9- Beaker

• 12 month old boy• Has been having

fevers, URTI symptoms for 24 hours

• Father has given him Children’s tylenol and tempra q4 hours for fevers, following the labels stringently

What’s a fever?

• http://www.caringforkids.cps.ca/handouts/fever_and_temperature_taking

Fever

• http://www.caringforkids.cps.ca/handouts/fever_and_temperature_taking

• Use of antipyretics is for symptom relief of aches and pains, does not change course of illness

• Other methods of fever reduction often helpful– Fluids, remove extra blankets and clothing (not

everything)

Case 9- Beaker

• Beaker weighs 12kg• Acetaminophen dosing in kids– 10-15mg/kg/dose q 4 hours (not to exceed 5

doses per day)– 15mg x 12kg = 180mg per dose

• Problems with father’s management?

Case 9- Beaker

• Tylenol (ACETAMINOPHEN)– Infants Acetaminophen liquid

• 80mg/1ml

– Childrens Tylenol liquid• 160mg/5mL

• Tempra (ACETAMINOPHEN)– Infant drops

• 80mg/mL

– Childrens Drops Regular strength• 80mg/5mL

– Childrens Drops Double Stength• 160mg/5mL

Case 9- Beaker

• 180mg of Childrens tylenol– 5.6mL = 180mg

• 180mg of Tempra– 11.25mL = 180mg

• Getting DOUBLE the recommended dose

Case 9- Beaker

• Ibuprofen– Do NOT give to child <6 months

• Dosing– 5-10mg/kg/dose q 6-8 hours– Beaker- 10X12 = 120mg q6 hours

• Typically 100mg/5mL– = 6mL

Fever

• Contact your health care provider if your child:– Has a fever and is less than 6 months old.– Has a fever for more than 72 hours. – Is excessively cranky, fussy or irritable.– Is excessively sleepy, lethargic or does not

respond.– Is persistently wheezing or coughing.– Has a fever and a rash or any other signs of illness

that worry you.

Objective 5

• Ask about family adjustment to the child (e.g., sibling interaction, changing roles of both parents, involvement of extended family).

Objective 5

• Simple questions to ask- but important• You will often pick up on specific stressors,

relationship issues with parents• Counsel and guide as needed- offer support