Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 6

Two-Week Visit

Candace F. Zickler

Breathing difficulties, 786.09

Poor feeding, 783.3

Decreased bowel movements, 564

Rash, 782.1

Irritability, 799.2

Reddened, draining umbilical site, 789.9

Jaundice, 782.4

Seizures, 780.39

Jaundice, newborn, 774.6

Vomiting, 787.03

No urine in 12 hours, 788.2

 

I. GENERAL IMPRESSION

A. Parents are settling in with 2-week old; each getting acquainted with other. If infant was still losing weight at discharge, the bilirubin was above 10 mg/dL, or the infant had a heart murmur, he/she needs to be seen in the office within 2 days.

B. Infant should have a naked weight, length on length board, and head circumference performed. Compare the birth weight and the discharge weight with the weight obtained today. Determine daily weight gain since discharge.

C. A brief exam noting muscle tone, symmetry, and heart sounds, murmurs should be done. Check for hip clicks by doing the Orolani and Barlow tests.

D. At 2 weeks of age, the infant's cord should have fallen off or be dry and looking like it will likely fall off soon.

E. Jaundice should be resolved except in some breastfed infants. If unresolved, do a transcutaneous bilirubin.

F. Newborn screen results should be reviewed and be negative. Share report with parents.

G. Review the newborn hearing screen. If hearing is within normal limits, share with the parents. If abnormal, schedule baby for an auditory brainstem response (ABR) or an otoacoustic emissions test (OAE) before leaving the office.

H. Reflexes present should be rooting, Galant's (trunk incurvation), placing and stepping, Landau (infant lifts head when suspended in prone position), asymmetric tonic neck.

II. NUTRITION

A. Breastfeeding is encouraged for all newborns. If mother is breastfeeding, ask specific questions:

1. Does the baby latch on well?

2. How long does the baby nurse at one time?

3. How frequently are you nursing the baby?

4. How many wet diapers?

5. How many stools?

6. Are you having any irritation or pain from your nipples?

Review all medications that mother may be taking (see Chapter 5). If mother expresses concerns about the nursing, observe a nursing session, give suggestions, and obtain a lactation consult from the hospital lactation resource.

B. If baby is bottle fed, review preparation and number of feedings, how much the baby is taking each time, number of wet diapers, and number of stools per day. Commercially prepared, iron-fortified formulas come in powder, concentrate, ready-to-feed. Do not dilute ready-to-feed. Follow directions for mixing concentrate and powder.

1. Do not reuse bottle if more than 4 hours since opened.

2. Mix formulas with bottled water for first month, continue to use bottled water if house is on well/unsure of water quality. Store mixed and open formula in refrigerator; do not feed formula that has been premixed and in the refrigerator longer than 24-36 hours. Specialized formulas have similar preparation directions; read labels. Goat's milk, whole cow's milk, rice milk have inadequate amounts of vitamins and minerals.

3. Serve formula at room temperature. Do not microwave to heat. Do not let formula sit out to warm for more than 15-20 minutes.

4. Clean technique is sufficient for mixing formulas. Clean off cans with soap and water before opening. Use hot soapy water and bottlebrush to clean nipples, bottles or clean in dishwasher.

5. Hold infant in upright, semi-reclined position; burp every 1-2 oz. No bottle propping. Babies will suck and then rest during the entire feeding. Encourage mother to let her husband/partner feed the baby at least once during the day.

6. No smoking or drinking hot beverages while holding baby. Limit noise in the immediate area when doing feeding, and focus on baby. Talk or sing to the baby.

7. Infant should take in 90 of feeding in first 20 minutes. Two-week old infant takes 3-5 oz/feeding, 5-6 feedings/24 hours (90-120 cal/kg/day).

III. ELIMINATION

A. Bowel movements should be formed or soft with no green color. Infant should have 1-6 yellow pasty stools/24 hours. Breastfed infant may have upper range of frequency with less formed texture. Void every 1-3 hours or with each feeding and diaper change.

IV. SLEEP

A. Awake and alert for feedings, every 2-4 hours. Should nurse vigorously for 15-20 minutes, then fall back to sleep.

B. Babies should sleep in own cribs to decrease smothering or injury. Babies should sleep on their back in cribs to decrease incidence of sudden infant death syndrome (SIDS).

V. GROWTH AND DEVELOPMENT

A. Growth.

1. Should regain birth weight by 2 weeks. Should gain 0.5-1 oz/day or approximately 2 lbs/month for next 5 months.

2. Infant grows, on average, 1 in./month for first 6 months.

3. Head circumference increases 0.5 cm/month in first year.

B. Development.

1. Moves all 4 extremities, keep hands fisted, and has flexed posture.

2. Has startle response to noises.

3. May have a smile. May begin to look for “who is talking.”

4. May have “fussy” time of 1-2 hours/day, often in evening.

5. Should have some supervised, “tummy” play time (15-20 minutes/session).

6. Ask about behavior after feedings to determine any colic or reflux.

VI. SOCIAL DEVELOPMENT

A. Babies have specific sounds/cries for specific needs. They will fuss/cry 1-2 hours/day. Providing for infant's needs should stop the crying. Crying gradually decreases by 3 months of age.

B. Infant needs holding; touching; feeding; dry, clean diaper; warm, yet comfortable environment.

C. Discourage taking baby to public places or visiting relatives since infant has not been immunized. Sick adults should stay away from infant.

D. Encourage mother to rest when baby rests/sleeps. Determine if night times are “awake times for the pair” and the mother is not getting her sleep.

VII. IMMUNIZATIONS (SEE APPENDIX A)

A. If mother is HBsAg-, infant may not have received first hepatitis B vaccine in newborn nursery and will need to get it today or before 2 months of age. If infant received hepatitis B immunization in the nursery, he/she will need to get four hepatitis B immunizations.

B. Infant should not have fever or fussiness from the immunization.

C. Discuss importance of getting immunizations. Many parents are concerned about risks. One in eight parents in the United States refused at least one recommended vaccine for their child.

VIII. SAFETY/ANTICIPATORY GUIDANCE

A. Sleep position “back to sleep.”

1. Not safe for baby to sleep in adult bed.

2. Discuss room temperature (comfortable), amount of clothing to put on baby (not to overdress infant).

3. No pillows/toys in the crib that could potentially smother child.

4. Federal motor vehicle safety tested and approved car seat: installed properly in backseat, facing backward in automobile. Contact local hospital, fire department, or local March of Dimes for car seat rental programs.

B. No smoking around infant.

C. Reassure parents they cannot spoil infant at this age.

D. Discuss sibling jealousy and possible regression of toddler. Encourage parent to spend “special time” with older sibling.

E. Discuss pet safety: Do not leave infant unattended near pet.

F. Discuss toys.

G. Discuss what to look for when choosing babysitter or daycare (e.g., handwashing, number of children, sick policy, feeding techniques).

H. One-piece pacifiers only, discuss appropriate use of pacifiers. Should not pin them on a string to baby's clothing, wash with soap and water if they fall out of the baby's mouth, do not lick or moisten it prior to giving to baby.

I. May give 1 oz of sterile water in 24 hours if stools are very hard. No corn syrup (Karo) for constipation.

J. No solids.

K. Remind parents of when and how to call healthcare provider. Review call-in phone policy and explain hours that are best to call office.

1. Breathing difficulties.

2. Seizures.

3. Irritability.

4. Poor feeding, vomiting.

5. No urine in 12 hours, black or decreased bowel movements.

6. Reddened, draining umbilical site.

7. Jaundice.

8. Rash or pustules not present on discharge.

9. Concerns.

BIBLIOGRAPHY

Car Safety Seats: A Guide For Families 2010. American Academy of Pediatrics Healthy Children website: http://www.healthychildren.org/English/safety-prevention/on-the-go/pages/Car-Safety-Seats-Information-for-Famiies-2010.aspx. Accessed June 2, 2011.

DeMichele AM, Ruth RA. Newborn Hearing Screening. Medscape Reference; 2010: http://emedicine.med-scape.com/article/836646. Accessed June 2, 2011.

Diekema DS, and Committee on Bioethics of American Academy of Pediatrics. Clinical Report: “Responding to Parental Refusals of Immunization of Children” Reaffirmed policy on May 1, 2009. American Academy of Pediatrics website: http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;115/5/1428. Accessed June 2, 2011.

Fouzas S, Mantagou L, Skylogianni SM, et al. (2009). Transcutaneous bilirubin levels for the first 120 postnatal hours in healthy neonates. Pediatrics. 2009;125(1):e52-e57. Retrieved from American Academy of Pediatrics website: http://www.pediatrics.org/cgi/content/full/125/1/e52. Accessed June 2, 2011.

Hagan JF, Shaw JS, Duncan P. (eds). Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. American Academy of Pediatrics; 2008: http://brightfutures.aap.org/3rd_Edition_Guidelines_and_Pocket_Guide.html. Accessed June 2, 2011.

March of Dimes. National Standard for Newborn Screening is Announced. Published May 21, 2010: http://www.redorbit.com/news/health/1869169/national_standard_for_newborn_screening_is_announced/. Accessed June 2, 2011.

March of Dimes. Pregnancy and Newborn: Newborn Screening Tests. 2010: http://marchofdimes.com/pnhec/298_834.asp. Accessed June 2, 2011.

Medoff-Cooper B, Bakewell-Sachs S, Buus-Frank ME, et al. (Near Term Advisory Panel). The AWHONN near-term infant initiative: A conceptual framework for optimizing health for near-term infants. JOGNN: Principles and Practice. 2005;34(6):666-671.

Rauch D. Neonatal weight gain. MedlinePlus website: http://www.nlm.nih.gov/medlineplus/ency/article/007302.htm. Accessed June 2, 2011.

Recommended Immunization Schedule for Persons Aged 0 through 6 Years–United States 2010. Centers for Disease Control and Prevention website: http://www.cdc.gov/vaccines/recs/acip. Accessed June 2, 2011.



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