Well Baby Care
CFPC 99 Topics Review
Ryan Kelly
June 16, 2015
CFPC Objectives for Well Baby Care
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.
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 Care
5. 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 evidencebased 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.
2.
3.
4.
5.
6.
Verify the accuracy of anthropometric measurements.
Plot the child's weight and length or height on the growth chart.
Calculate mid-parental height to estimate the child's growth potential.
Obtain a complete history and perform a physical examination.
Assess caloric intake using a food diary analysed by a trained nutritionist.
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/childgrowth-charts
– http://www.cps.ca/documents/position/toddlerfalling-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/program
s/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
disorderagammaglobulinemia
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 vaccineshow 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 atrisk 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/fee
ding_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/fev
er_and_temperature_taking
Fever
• http://www.caringforkids.cps.ca/handouts/fev
er_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