Pediatric Primary Care Case Studies, 1st Ed.

Chapter 6. The Well Infant

Anna Marie Hefner

A newborn baby, whether it is the first or last child, is unique and brings changes to family dynamics. The initial newborn visit provides a special opportunity for the healthcare provider to discuss the mother’s pregnancy and delivery, immediate postpartum mother and infant issues, and plans for individualized care of both the baby and family. For the discharge of a mother and her newborn occurring within 24 to 48 hours after childbirth, the American Academy of Pediatrics recommends that the first office visit occur as early as 2 days after discharge. Factors that determine the timing for scheduling this first visit include the healthcare needs of the newborn, the date of discharge of the mother and infant, and the concerns of the family.

According to the American Academy of Pediatrics (2004, p. 1435), the purpose of the initial visit is to:

•  Weigh the infant; assess the infant’s general health, hydration, and degree of jaundice; identify any new problems; review feeding pattern and technique, including observation of breastfeeding for adequacy of position, latch-on, and swallowing; and obtain historical evidence of adequate urination and defecation patterns for the infant

•  Assess quality of mother–infant interaction and details of infant behavior

•  Reinforce maternal or family education in infant care, particularly regarding infant feeding

•  Review the outstanding results of laboratory tests performed before discharge

•  Perform screening tests in accordance with state regulations and other tests that are clinically indicated, such as serum bilirubin

•  Verify the plan for health care maintenance, including a method for obtaining emergency services, preventive care and immunizations, periodic evaluations and physical examinations, and necessary screenings

Educational Objectives

1.  Apply the guidelines for management of newborn health care, including prenatal history and childbirth, assessment of infant’s general health, reviewing feeding patterns and technique, preventive care and immunizations, physical examination, and necessary screenings.

2.  Assess the quality of mother–infant interaction.

3.  Identify the strengths of the family and reinforce family education in infant care.

4.  Consider the cultural factors that might affect the healthcare plan and the family’s understanding and compliance with the plan of care.

  Case Presentation and Discussion

Lauren Calzada is a 4-day-old Mexican American female born to a 34-year-old gravida 2 para 2 Mexican American mother in a common law marriage. She has a previous male child, Anthony, born 3 years ago. She explains that her newborn daughter is breastfeeding every 2–4 hours and is healthy; however, the 3-year-old is whining all the time. She has noticed Lauren is more “yellow” than Anthony was at birth. Ms. Calzada is concerned about the jaundice Lauren is exhibiting.

What initial questions need to be asked of Ms. Calzada? image

The healthcare provider should establish a baseline history that includes information about the following:

•  Pregnancy: Para and gravida status, when she first sought prenatal care, any maternal health problems (e.g., toxemia of pregnancy or gestational diabetes), any fetal health issues.

•  Labor: Length and complications.

•  Delivery: Type of delivery, use of instruments, any maternal or fetal complications.

•  Hospitalization: How soon after birth was the infant discharged home?

•  Neonatal course or issues since discharge: Feeding, voiding, sleeping, and any worrisome symptoms or signs or parental concerns.

Ms. Calzada says she remained healthy during her pregnancy. Her labor was unremarkable, with a spontaneous vaginal delivery 6 hours after the first contractions, just 2 days before her due date. Ms. Calzada had a small labial laceration requiring sutures with no further complications. Lauren had a “small lump on the left side of her head” (cephalohematoma) at delivery, but no other problems were noted after delivery or during the hospital stay. Ms. Calzada breastfed Lauren in the delivery room and experienced no breastfeeding problems. She and Lauren were released from the hospital 36 hours after delivery, and since then Lauren has been breastfeeding every 2–3 hours and voiding adequately.

Last evening she noticed Lauren had “yellow cheeks,” and by morning the jaundice appeared on the baby’s chest. She called the healthcare provider and made a late morning appointment.

What additional questions will you ask Ms. Calzada related to the jaundice? image

Before answering this question, here is essential information about jaundice in the newborn that you need to consider.

Pathophysiology of Newborn Jaundice

Jaundice results from the deposition of unconjugated bilirubin in the skin and mucous membranes. It is a result of the shortened life span of the red blood cells, declining hematocrit, immature liver uptake and conjugation of bilirubin, and increased reabsorption of bilirubin in the intestines. The common risk factors include ABO incompatibility, prematurity, breastmilk jaundice, and a previously affected sibling.

Additionally, cephalohematomas, bruising, and trauma from an instrumented delivery may increase the risk for elevation of serum bilirubin. Ms. Calzada told you about Lauren’s “bump” and the hospital record noted a cephalohematoma on the left temporal area. In a cephalohematoma, there is a collection of blood under the periosteum. This blood breaks down into heme, which becomes bili and may contribute to jaundice, and iron, which is recycled into new red blood cells. However, jaundice is present to some degree in most newborns and is known as physiological jaundice (De Almeida & Draque, 2007).

Jaundice can be detected when blanching of the skin reveals a yellow color. It starts on the face and progresses caudally. The higher the total bilirubin, the further it progresses down the body (Johnson, Bhutani, & Brown, 2002). Jaundice is difficult to detect in dark-skinned newborns. The examination should always occur in a well-lit room.

Other information you should obtain includes the following:

•  What is the mother’s blood type and baby’s blood type?

•  What is the Rh factor of the mother?

•  Has the baby had a fever?

•  Has the baby or the mother been exposed to any person or persons with an infection in the 2 weeks prior to delivery?

•  What have the baby’s feeding and voiding patterns been since discharge from the hospital?

•  What was the mother’s first pregnancy experience like and was she able to successfully breastfeed her first child?

Your further questioning reveals the following additional information:

According to Ms. Calzada, Lauren breastfeeds every 3–4 hours, 5 minutes on each breast. She has approximately four to five wet diapers a day; the urine is dark yellow in color. Ms. Calzada reports that Lauren has had one green stool since discharge. There were no exposures to individuals with infectious diseases in the 2 weeks prior to her delivery or since then. Her first pregnancy resulted in a healthy, term male infant without complications. She was successful in breastfeeding Anthony for his first year of life.

You review the results of the laboratory studies conducted during their hospital stay.

The laboratory reports note that Ms. Calzada’s blood type is O+, Lauren is A+, direct Coombs negative. Lauren’s total bilirubin at 12 hours was 1.8 mg/dL.

The healthcare provider should also discuss Lauren’s sleeping schedule. Ms. Calzada tells you that Lauren is sleeping longer stretches of time, almost 4 hours at times, allowing her to get the housework done.

Social History

Lauren’s father is deployed in Iraq and will be on leave in 4 months. Ms. Calzada’s mother is expected to arrive in 1 week and will stay with her daughter for 1 month. They live in two-bedroom military base housing, and Ms. Calzada has a few friends who come by when they can. Her church provides her meals since she has been home each evening. She says, “I’m coping OK. My church friends are a big help but I’ll be happy to have my mother come and help me.”

Physical Examination

The vital signs are T 37° Celsius, pulse 142, respiratory rate (RR) 48, weight 3.2 kg (45th percentile), length 50 cm (75th percentile), and head circumference 34 cm (75th percentile). The infant is jaundiced to the abdomen. The anterior fontanel is flat and slightly sunken; oral mucosa is moist. No cephalohematoma or bruising is present. The sclera of both eyes are clear. Muscle tone and activity are normal. Reflexes: suck and swallow strong and coordinated, rooting intact. The remainder of the physical exam is normal.

Making the Diagnosis

Differential Diagnosis

The differential diagnoses for jaundice in the newborn include ABO incompatibility, infection, physiological jaundice of the newborn, and breastmilk jaundice.

This history and physical examination are consistent with a diagnosis of physiological jaundice and may be exaggerated with breastfeeding jaundice. She has jaundice to the abdomen, breastfeeding every 3–4 hours, and a history of a cephalohematoma.

Other problems that need to be addressed include:

•  Breastfeeding techniques

•  Military family with husband deployed

How do you plan to treat the jaundice? image

Do you need to do anything to confirm the diagnosis, such as laboratory studies? image

At this time, a total and direct bilirubin would need to be done. The laboratory results for Lauren are total bilirubin of 6.8 mg/dL with a direct bilirubin of 0.1 mg/dL. Additional testing would need to be done if there were additional symptoms such as a fever, listlessness, increased irritability, or poor feeding. A complete blood count, reticulocyte count, and serum albumin levels may also need to be checked.

Therapeutic plan: What will you do therapeutically? image

Treatment is not usually necessary with physiological jaundice. However, Lauren would need to be kept hydrated. Mother can increase the frequency of breastfeeding to every 2–3 hours during the waking hours and allow baby to sleep up to 4 hours at night. Physiological jaundice usually resolves within 1 to 2 weeks.

Educational plan: What will you do to educate Ms. Calzada about breastfeeding and its management? image

Jaundice

Ms. Calzada needs to bring Lauren back to the healthcare provider if the baby develops a fever, becomes listless, or is not feeding well. Jaundice is usually not dangerous in the term healthy newborn. Additionally, Ms. Calzada should call the provider if the jaundice becomes more severe, lasts longer than 2 weeks, or if other symptoms develop.

Nutrition: Breastfeeding

Breastfeeding should be for a minimum of 10 minutes on each breast or until the baby is content. Watch Ms. Calzada breastfeed her infant. Review how to hold the baby and correct latching on, if you note problems with her technique. Discuss that newborn infants typically demand feedings 8 to 12 times per day for the first 4 to 6 weeks of life. Lauren can also receive sunlight through adequate exposure to indirect sunlight. Lauren’s mom can place the baby by a window that has sun exposure, but not in such a position that the sun is directly shining on the infant. Mom can also take the baby outside with her to sit in the shade on a warm day. Discussion of bowel movements—frequency and transitional stools, voiding patterns of six to eight wet diapers per day—should also be addressed.

What other areas of education and anticipatory guidance are needed for the family? image

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents (Hagan, Shaw, & Duncan, 2008) identifies three key areas of anticipatory guidance that should be addressed at each well child visit. Because this sick visit is focusing on the assessment and management of Lauren’s jaundice, you will not want to overwhelm the mother with extensive healthcare teaching. The healthcare provider should mainly use this time to address the issue of jaundice brought forth by the mother. However, the healthcare provider should also discuss at least one to two anticipatory guidance issues (e.g., car seat use and limited outings) at this visit and explain to Ms. Calzada that they will be discussing anticipatory guidance issues at future wellness visits. The clinician will need to identify what anticipatory guidance topic or topics should be a priority issue addressed at this time. The focus could be a safety, sleep, or general infant care issue that emerged from information obtained during the history and examination of the infant. Keep in mind that a discussion about safety, such as the use of an infant car seat, is always an appropriate issue to address at every healthcare encounter.

Subsequent visits will address the following areas of anticipatory guidance:

•  Promotion of healthy and safe habits

image  Car seat safety: Position the newborn in the back seat of a car, facing backwards, following manufacturer’s instructions and the vehicle’s owner manual. The infant needs to remain in the car seat at all times during travel.

image  Crib safety: Slats in the crib should be no further than 2⅜ inches apart.

image  Smoke-free environment: Families should make their home and car nonsmoking zones.

image  Home safety: The baby should never be left alone in water or on high places such as changing tables, beds, chairs, or sofas. Keep one hand on the baby.

image  Hygiene: Caregivers’ should wash their hands with soap and water frequently, especially after diaper changes and before feeding the baby.

•  Infant care

image  Outings: The newborn is susceptible to illness and needs to be protected from anyone with a cold or illness. Consider carefully the necessity of bringing the newborn on outings such as trips to the grocery store, faith-based activities, and restaurants in order to avoid persons with colds or flu.

image  Cord care: Air dry the cord by keeping the diaper below the cord until the cord falls off (about 10–14 days). There may be some slight bleeding for a day or two when the cord falls off.

image  Prevent diaper rash: Clean baby and air dry after each diaper change. Change diaper frequently.

image  Bathing: Baby’s skin does not need to be washed daily with soap. Tell the mother to wipe the baby’s genital area with each diaper change and to avoid detergent-based soaps. Newborn infants need to be bathed every few days and as needed.

image  Cradle cap prevention: Wash scalp (every other day to daily) with baby shampoo or mild soap such as Dove. Demonstrate washing the scalp to the parent to reassure and decrease fear of touching the “soft spot.”

image  Temperature taking: Review the procedure of taking a temperature with the parents.

•  Feeding

image  Feeding times: Feed the baby when hungry. Signs of hunger include sucking, rooting, fussing, and putting hand to mouth.

image  Burping and spitting up: Burp baby by gently rubbing or patting their back while holding the baby against your shoulder and chest or supporting the baby in a sitting position on your lap. Burp midway through feeding and at the end of feeding. Babies can have “wet burps” up to 30 minutes after feeding.

Military Family Needs

The military family has unique needs based on deployment in times of war, training assignments, and potential reassignment to another base. Children of military personnel have universal access to Tricare, the military health insurance. Parents can then secure health care for their dependents in military facilities or through civilian options (Budzik, 2008).

Military deployments, whether to war torn areas or just for training sessions outside of their home base station, are often stressful times for these families, some of whom may be temporarily displaced when such assignments occur. The ability of a military family to acclimate to deployments and family separation may vary from those who have an affinity to cope well with the cycle of military moves and/or deployment to those whose lives are thrust into turmoil. Although, Ms. Calzada’s children are very young, the healthcare provider should be alert to potential problems that children may also experience. Research focusing on the effect of deployment in children reveals that children can be impacted by the separation caused by deployment for extended periods of time. Budzik (2008) noted that research conducted with military families during Operation Desert Storm demonstrated that children of deployed soldiers experienced increased symptoms of depression; however, their symptoms were rarely pathological. Lamberg (2004) noted that some children became more confident and independent during times of deployment for their parent. Gibbs and colleagues (2007) investigated the incidence of maltreatment of children of enlisted soldiers during times of deployment and noted an increase in the incidence rate during times of deployment. Thus, the implications of these studies clearly validate the need for families left behind, like the Calzadas, to receive the emotional, psychosocial, and sometimes financial support they need.

Ms. Calzada now has two children with a husband in Iraq and is awaiting help from her mother. A study by Giles (2005) found that Army wives appear to suffer from high levels of stress, and their coping mechanisms were affected by constant turbulence and isolation. He noted that Army dependents require more support from their healthcare provider than the average civilian family.

Because of the isolation Ms. Calzada may feel, the healthcare provider needs to be alert for the development of postpartum depression and symptomatology of isolation. Assessing for postpartum depression should be an integral part of well child visits during the next 6 to 12 months. Healthcare providers must be proactive in providing support and alternative services. In Ms. Calzada’s situation, you should discuss whether there are services on base for new mothers. She is currently using her church support system to help care for her children until her mother arrives. Additionally, when her husband returns in 4 months, the healthcare provider should encourage her to seek out military services that are available to them to promote a positive integration of the family after his experiences in Iraq. Proactive intervention can help the family better cope with “after effects” of potential postdeployment stressors. In addition, acknowledge Ms. Calzada’s decision to utilize resources such as her church family during the fourth trimester.

The military has an Operation Homefront program (accessed at http://www.operationhomefront.net) that is an excellent resource that provides emergency assistance and morale to troops, to the families they leave behind, and to wounded warriors when they return home. The Department of Defense has a Web site called Military Homefront dedicated to providing information to help troops and their families and service providers (http://www.militaryhomefront.dod.mil). Civilian healthcare providers may find this Web site beneficial when caring for military families.

When do you want to see this patient back again? image

This patient should be scheduled to come back in a week to be rechecked. However, if Lauren develops any symptomatology (as identified in the educational plan), she will need to be seen earlier.

Key Points from the Case

1. Treatment of jaundice depends on the cause of the jaundice. In Lauren’s case, it was physiological jaundice. She needs to be kept hydrated and the jaundice should resolve in 10–14 days.

2. Breastfeeding every 2 to 3 hours, nursing 8 to 12 times in a 24-hour period, is expected during the first few days of life. By 1 week of age, the newborn should be breastfeeding every 2 to 3 hours with longer stretches up to 4 hours for sleeping.

3. The role of the provider is to help the new family deal with specific issues, health issues, and the needs of the mother and baby. It is a supportive role as the family makes adjustments to the new family member. Education and anticipatory guidance can help alleviate unnecessary anxiety.

4. Military families have special needs as parents that need to be addressed.

REFERENCES

American Academy of Pediatrics, Committee on Fetus and Newborn. (2004). Hospital stay for healthy term newborns. Pediatrics, 113, 1434–1436.

Budzik, C. (2008). Providing well child care for military families: What every provider needs to consider. Pediatric Annals, 37(3), 185–188.

De Almeida, M. F. B., & Draque, C. M. (2007). Neonatal jaundice and breastfeeding. Nurse Research, 8(7), 282–288.

Gibbs, D. A., Martine, S. L., Kupper, L. L., & Johnson, R. E. (2007). Child maltreatment in enlisted soldiers’ families during combat-related deployment. Journal of the American Medical Association, 298, 528–535.

Giles, S. (2005). Army dependents: Childhood illness and health provision. Community Practitioner, 78(6), 213–217.

Hagan, J. E., Shaw, J. S., & Duncan, P. (Eds.). (2008). Bright futures guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Johnson, L. H., Bhutani, V. K., & Brown, A. K. (2002). System-based approach to management of neonatal jaundice and prevention of kernicterus. Journal of Pediatrics, 40(4), 396–403.

Lamberg, L. (2004). When military parents are sent to war, children left behind need ample support. Journal of the American Medical Association, 292(13), 1541–1542.