Pediatric Primary Care (18 page)

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.

CHAPTER 8

Two-Month Visit

Candace F. Zickler

I.  GENERAL IMPRESSION

A.  Parents should be enjoying their infant and taking joy from infant's accomplishments.

B.  Infant is more responsive with smiling and cooing.

C.  Parents should have many questions and be able to share stories of babies' activities.

II. NUTRITION

A.  Two-month old infant will take 6-8 oz/feeding, 4-6 feedings/24 hours (94–130 cal/kg/day). Feedings should be more predictable and infant should have periods when he/she sleeps for 3-4 hours at a time.

B.  Baby should take in 90 of feeding in first 20 minutes.

C.  Hold infant in semi-reclined position; burp every 1–2 oz.

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

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

F.  Clean technique is sufficient for mixing formulas.

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

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

G.  No bottle propping. Pacifiers are used for non-nutritive sucking. Breastfeeding should be well established before starting infant on a pacifier, but babies who suck pacifiers are at decreased incidence of sudden infant death.

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

III. ELIMINATION

A.  Should have 1–5 yellow pasty, but formed stools/24 hours.

B.  Breastfed babies may have more stools than bottle-fed babies.

C.  Void every 1–3 hours or with each feeding and diaper change.

IV. SLEEP

A.  Babies sleep 16–18 hours/24 hours. Infant is developing sleep pattern. May sleep through night. May have longer awake periods during day.

B.  Sleep cycles have both active and quiet sleep periods in equal proportions. Each sleep cycle lasts 50–60 minutes. Infants are less efficient with sleep and easily interrupted with noise. Should be alert for feedings, nurse vigorously for 15–20 minutes, and fall back to sleep/stay awake for short periods.

C.  Babies should sleep in own cribs, not with parents, to decrease smothering injury to infant.

1.  Babies should sleep on back in cribs to decrease incidence of sudden infant death syndrome (SIDS).

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

V.  GROWTH AND DEVELOPMENT

A.  Growth. Plot length, weight, head circumference, and weight-for-height on the National Center for Health Statistics (NCHS) growth grids. Compare to last visit growth plots.

1.  Babies should gain 0.5–0.75 oz/day or approximately 2 lbs/month for the first 4–5 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.  Holds head upright for short periods. Follows people and looks for voice.

2.  Responds to smiling with return smile.

3.  Babbles and makes sounds with prompt of verbal cue.

4.  Shows interest in what is happening in room.

5.  Moves all 4 extremities, simultaneously.

6.  May cry but parents are learning what each cry means. Crying ceases when needs are met.

VI. SOCIAL DEVELOPMENT

A.  Baby learning to “trust” parent and caretakers to meet needs.

B.  Family is settling into routines with infant.

C.  Listen carefully for frustration, potential for abuse/neglect. Discuss child's unique temperament characteristics, relate to parents' feelings.

D.  Parent should be assessed for sadness, depression, fatigue.

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

2.  Encourage mother to take breaks away from baby to do self-nurturing (needs designated sitter).

E.  Take baby on selective, limited outings because infant is not fully immunized; will only receive first set today.