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

CHAPTER 7

One-Month Visit

Candace F. Zickler

Breathing difficulties, 786.09

Poor feeding, 783.3

Decreased bowel movements, 564

Seizures, 780.39

Irritability, 799.2

Vomiting, 787.03

No urine in 12 hours, 788.2

 

I. GENERAL IMPRESSION

A. Parents and infant should be settling into routine and more comfortable with each other. Parent should be very attentive to the infant and have lots of questions. There should also be a sense that parent is comfortable with the infant. Parent is able to describe characteristics of infant's temperament. Mother should have someone identified that she can leave baby with for brief periods of time.

II. NUTRITION

A. Breastfeeding is to be encouraged. Determine if baby is satisfied after feedings, how frequently baby is nursing, how long a feeding takes, and any concerns mom has about continuing nursing. Ask about plans/arrangements to return to work.

B. Formula.

1. Mix formula with bottled water for first month, continue to use bottled water if house is on well/unsure of water quality. Have well water tested at local health department for small fee.

2. Store ready-to-feed and open formula bottles in refrigerator. Refrigerate no longer than 24-36 hours.

3. Specialized formulas have similar preparation directions; read labels. Goat's milk, whole cow's milk, rice milk have inadequate amounts of vitamins and minerals.

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

5. Clean technique is sufficient for mixing formulas.

a. Clean off cans with soap and water before opening.

b. Use hot soapy water and bottlebrush to clean nipples and bottles or clean in dishwasher.

6. Hold infant in upright, semi-reclined position; burp every 1-2 oz.

a. No bottle propping.

b. No smoking or drinking hot beverages while holding baby.

7. One-month old infant will take 4-6 oz/feeding and 5-6 feedings/24 hours (90-120 cal/kg/day).

III. ELIMINATION

A. Should have 1-6 yellow pasty stools/24 hours.

B. With each feeding, breastfed infant may have softer, formed/seedy stools.

C. Void every 1-3 hours or with each feeding.

IV. SLEEP

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

B. Babies should sleep in own cribs, not with parents, to decrease risk of smothering or injury.

C. Babies should sleep on back or side in cribs to decrease risk of sudden infant death syndrome (SIDS).

D. No pillows/toys that baby could get face against and smother.

V. GROWTH AND DEVELOPMENT

A. Growth. Weigh infant naked on infant scales. Compare weight to last visit. Calculate rate of gain since last visit. Measure length on length board and head circumference. Plot values on National Center for Health Statistics (NCHS) growth chart. Discuss your findings from the growth charts.

1. Should gain 0.5-1 oz/day or approximately 2 lbs/month for next 4 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. Responds to human face and follows briefly with eyes. Is attentive to sound of parent's voice.

1. May be able to lift head off bed if on tummy.

2. May have a smile.

3. Has positive red reflexes bilaterally and blinks to light. Tear ducts may have tears appear; tear ducts should be patent.

4. Assess scalp for cradle cap and diaper area for dermatitis. Review how to care for baby's skin.

Examine baby's mouth for teeth, intact palate, and presence of thrush. If bottle-feeding and thrush is found, discuss cleaning of pacifiers, nipples. If breastfeeding, review washing nipples before feedings, and applying antifungal (prescription) after feedings.

5. Gently palpate abdomen looking for masses, and location of the liver.

6. Observe movement of all 4 extremities, usually simultaneously. Has a flexed posture and keeps hands fisted.

7. May cry but parents are learning what each cry means; crying ceases with needs being met. Cry gradually decreases by 3 months of age.

8. May have “fussy” time of 1-2 hours/day, often in evening. Use “fussy” time as interaction time, not extra feeding.

9. Baby may have symptoms of “colic” start around 2-3 weeks of age. Infant cries for prolonged periods, no specific cause or pathology identified. Infant requires additional comfort measures to quiet and settle.

VI. SOCIAL DEVELOPMENT

A. Parent should be assessed for sadness, depression, fatigue. Parent should show attentive, animated behavior toward baby. Listen carefully for frustration, potential for abuse/neglect.

B. Parents should hold, cuddle, and talk to infant when awake. Infant should have 15-20 minutes of “tummy time” with supervision, daily.

C. Discourage taking baby to public places or visiting relatives because no immunizations as yet.

D. Encourage mother to rest when baby rests/sleeps.

E. Baby is learning to “trust” parent and caretakers.

VII. IMMUNIZATIONS (SEE APPENDIX A)

A. If mother is HBsAg-, infant may not have received hepatitis B #1 in newborn nursery or at 2-week visit. Will need to get it today.

B. Discuss need for immunizations at next visit. Parents hear many negative remarks from friends and family and the Internet. But they do listen to a trusted healthcare provider.

C. Infants should not have fever or fussiness from immunization.

VIII. SAFETY/ANTICIPATORY GUIDANCE

A. Sleep position “back to sleep.”

B. Protect baby from direct sunlight. Skin is very sensitive and they burn easily.

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

D. Temperature of room comfortable. Discuss type of clothing needed to dress infant for inside, outside, and for bed.

E. A Federal Motor Vehicle Safety Standards seat (FMVSS) should be installed properly in backseat, facing backward in their automobile. Contact local hospital, fire department, or March of Dimes chapter for car seat rental program.

F. No smoking around infant. Do not drink hot beverages when holding baby.

G. One-piece pacifiers only. Do not pin it to the clothing.

H. No corn syrup (Karo) for constipation. May give 1-2 oz of sterile water daily for infrequent or hard stools.

I. Infant still not old enough to be fed solid foods. Diet should be breastmilk or formula.

J. Obtain CPR training. Make sure smoke alarms are working and functional in the home.

K. Remind parents of when and how to call the healthcare provider.

1. Breathing difficulties.

2. Seizures.

3. Irritability, lethargy.

4. Poor feeding, vomiting, diarrhea (describe how stools would be if diarrhea).

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

BIBLIOGRAPHY

Car Safety Seats: A Guide For Families 2011. American Academy of Pediatrics Healthy Children website: http://www.healthychildren.org/English/safety-prevention/on-the-go/Pages/Car-Safety-Seats-Information-for-Families.aspx. Accessed July 20, 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.

Centers for Disease Control and Prevention. Growth Charts for Birth through 36 Months. CDC website: http://www.cdc.gov/growthcharts/clinical_charts.htm. 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.

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.

Task Force on Sudden Infant Death Syndrome. The Changing Concept of Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies Regarding the Sleeping Environment, and New Variables to Consider in Reducing Risk. American Academy of Pediatrics website: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;116/5/1245. Accessed June 2, 2011.

Tips and Tools: Safety for Your child; Birth to 6 Months. Retrieved from http://www.healthychildren.org/english/tips-tools/Pages/default.aspx. Accessed June 2, 2011.



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