Infant Care

00:01 All right, happy times, let’s talk about examination of the healthy infant, nothing like seeing a nice healthy infant in front of you.

00:08 And good care for the infant actually starts well before the infant arrives in your practice.

00:13 So first of all, the waiting room.

00:16 You really want to set up a divide between well patients and sick patients and I’ve actually seen divides of well, sick, and rash patients before.

00:26 But you don’t want the kids to mix together and because they don’t really pay much attention to the germ theory of disease and they’re all over one another, so therefore, keep a well side and a sick side in your waiting room.

00:39 Support staff is really critical in doing well child care because you’ll frequently have to check things like hearing, vision, these take time, so does the application of vaccines and doing that correctly.

00:52 So you want to have toys available like this waiting room is a good example, seating appropriate for young kids.

00:58 Having stickers goes as long, long way as to making the owies feel better and the kids stop crying.

01:06 Very importantly from a medical side, you’re going to want to follow weight and height assiduously in these kids.

01:14 You also are going to want to be checking vaccine records and one of the more flummoxing things is when you have a child and they seem to be underweight but you don’t know their weight from two months ago and you don’t know their vaccine history, and that leads to delays in care, and therefore, they’re less likely to get good care, they’re less likely to be vaccinated.

01:34 And really, I found that it takes a team to provide a good care, particularly to infants who require so many vaccinations, and so watch the folks who give vaccines, they should have skill in grouping together the vaccines, getting all the charting and the consents from the parents out of the way first.

01:55 And then when it comes show time to hold that baby down and do the vaccines, it should be very, very efficient.

02:01 All ready to go, not like fiddling with things or, “Oh, I’ve got to run out of the room again for a second.” You really want to get them over with.

02:09 I’ve been very impressed with our personal pediatrics practice in doing this.

02:15 Anything that involves a kid and maybe it’s a little bit harder among infants, but you can still play peekaboo with them.

02:21 But I always give it the chance for young children to manipulate the stethoscope, understand it’s not going to be harmful.

02:27 Try to make games as you go along of looking into the ears, of checking for the red reflex.

02:32 Those can be tricky, and so therefore, the more it’s a game, it can be more fun for the kids, you know you’ll get better participation.

02:38 And of course, you need good communication with the family because kids can’t give their own histories.

02:44 So what’s the usual schedule? What’s recommended for well child visits during that first year of life? Within three to five days after birth, I think that’s a critical time to ensure that healthy habits are instituted, breastfeeding is going on, there’s no evidence of jaundice, and that the home is safe and that everybody is adjusting to the new edition well.

03:05 And then at one month, two months, four months, six months, nine months, and a year.

03:11 So a baby who is born on January 1st should have a schedule that looks something like that.

03:19 How about breastfeeding? Of course, we recommend breastfeeding, it’s associated with a lot of health benefits we’re going to go over.

03:24 These might be on your examination.

03:27 At least the first six months should be exclusive breastfeeding and a strong consideration should be paid to continuation of breastfeeding through one year.

03:36 But even for women who stop at six months, most of these benefits that I’m about to describe to you were among women who were studied to breastfeed for at least six months.

03:46 So therefore, six months is something of an achievement in and of itself because it is associated with lower risks of asthma for the infant in childhood, lower risks for obesity moving on, and, thus, diabetes, lower risks for serious infections such as pneumonia, and a lower risk for sudden infant death syndrome as well.

04:05 For the mother, there are also some benefits.

04:07 If, say, you have a selfish mother and she wants to know, “Well, what is in it for me for breastfeeding?” because it is a lot of work, tremendous respect for every mother out there who breastfeeds because I’ve witnessed just how much of work it is.

04:21 So dads, you have to pitch in and you get to do everything else because breastfeeding is a lot of work and it does come with some benefits.

04:28 Lower risk of ovarian and breast cancer and improved bonding between mother and infant as well.

04:35 All right.

04:36 What about problems that you can see even very early in childhood like right after birth with neonatal jaundice during the neonatal period? So just to recall that preterm infants are at higher risk and therefore they should be monitored every eight to twelve hours for jaundice.

04:50 And that is more or less standard practice I think for every infant in the hospital, while we want them to room with the parents and that’s healthier, it’s more better for bonding, better for initiating and maintaining breastfeeding versus the babies in a nursery, they should still be checked by the staff for jaundice.

05:11 Transcutaneous bilirubin is great, it’s noninvasive and it’s about equally useful as serum bilirubin levels.

05:19 It’s hard to get into exactly when to initiate treatment using phototherapy, but there are nomograms, which I refer to, and it’s based on the hours since birth, and it allows you to appropriate risk stratify which children are at risk for kernicterus, which is an uncommon outcome of hyperbilirubinemia, but it can occur and it’s devastating, obviously you want to avoid it.

05:46 For patients with rising bilirubin, definitely get a blood type and a Coombs' test.

05:51 Consider G6PD testing, as well, for glucose-6 phosphate disease because these children with jaundice may be at higher risk.

06:01 How do you prevent neonatal jaundice? Well, we know that breastfeeding can -- breastmilk can promote jaundice for a period, but that is nearly always benign, so breastfeeding in and of itself is helpful up to 8 to 12 breastfeeds per day.

06:17 And once jaundice is identified, that is non-indication of itself to reduce breastfeeding, only in severe jaundice would that be a consideration.

06:26 You want to continue the breastfeeding.

06:28 And most cases, just remember that most cases do resolve either spontaneously or with phototherapy, which can be given within the hospital or at home, but the key is careful monitoring.

06:42 In the cases, they are monitored closely and applying that nomogram to put the patient in the right category of risk and treatment, it’s very rare to have any serious complication.

06:56 So what about some concerns that parents may have during infancy? Sleep is always important because that’s what the kid does most of the day.

07:03 Sleep should always be -- the patient should always be on the back.

07:06 So the baby should always be face up and that’s to prevent sudden infant death.

07:12 It’s been strange to look at cribs and there’s nothing in there, there’s no toys, there’s no bumpers around, there’s no blankets, because a generation ago all that stuff was really in vogue.

07:25 Now we know all those things, unfortunately, can promote a higher risk of SIDS, and therefore, should be eliminated.

07:31 So really, it’s just the baby.

07:33 They may be swaddled in a blanket, but it shouldn’t have any loose materials within their crib.

07:39 Average number, average sleep, remember, it’s very high.

07:43 So parents should be aware that 14 to 17 hours per day is normal for newborns, among infants it’s 12 to 15 hours per day.

07:51 And of course, parents are concerned with night waking and they want to think about, well, what’s the best way? It is exhausting to take care of a newborn and an infant many times, and so therefore, they’re going to have lots of questions.

08:03 Do try to tell them that for most infants, night waking by age six months is going to be pretty infrequent.

08:10 It’s rare to have a child who’s waking up two or three times per night.

08:13 Usually it’s along the lines of maybe once or twice per night.

08:19 And it’s really hard to recommend one form of training versus another.

08:24 So there is the model of care which just says let the baby cry, and generally, I wouldn’t recommend that at all for the first couple of months of life, but after that it might be more of a reasonable approach, versus the more supportive model of going in and comforting the baby and doing a feed on demand.

08:49 Either one of these techniques can promote parental anxiety and burnout, which is not good, and I think it’s best to have a framework for what you want to do, but keep it flexible because certainly when your child has a fever, you’re not going to ignore that baby who’s crying or they might be in some other form of distress.

09:10 And likewise, you don’t want to be rushing in to, you know, every time they’re crying when they’re 15 months old.

09:18 So avoiding the extremes and kind of keeping it flexible based on your child’s condition is important.

09:26 And one thing that really helps is of course a bedtime routine of keeping things calm, soothing, and that sets things up nicely for when they hit older ages, you know, one year and beyond, where they understand okay, it’s time to settle down, it’s time for bedtime.

09:42 What about pacifier use? That’s a big question as well.

09:45 Actually, pacifier use can improve the risk of SIDS through six months, but over time it’s also associated with a higher risk of otitis media, kids who use pacifiers more often tend to wheeze more, and it’s associated with dental malocclusion and dental abnormalities over time.

10:03 Bottom line with pacifier use is, again, I have young children, I can personally vouch for how valuable it can be, particularly for younger infants, but by the time six months happens, it’s time for the aliens to start abducting the pacifiers from around the room and suddenly they just start disappearing.

10:22 There’s not as many as there once were.

10:24 So really try to wean off the pacifier, certainly, and you could start at six months, that’s perfectly reasonable.

10:32 For vaccinations, there are too many vaccinations to describe individually, but we certainly try to stick to what’s recommended from the Centers for Disease Control.

10:42 Really try to stay away from vaccine delays.

10:46 The typical excuse is, “My baby had a fever three days ago. They’re getting over a cold. I don’t want to get them sick so can we just wait on my vaccines?” You know, “Oh, that’s so many vaccines. Why don’t we split them up, we’ll give two this time and I swear I’ll come back in a month and we’ll do two next time too.” All of these things are associated with not completing the vaccination schedule and so I really try to discourage that.

11:09 Try to keep the kids on schedule, unless they have a real contraindication for vaccines that day, keep them on schedule.

11:16 At the end of the day, they’re going to be better protected and you’ll save the parent a lot of time in going back and forth between visits.

11:25 You can reassure parents there was this potential association between vaccinations such MMR and autism, That’s been completely disproven, there’s no link between vaccinations and autism.

11:37 And in kind of going the opposite way, outbreaks of preventable infectious illnesses such as pertussis and measles are leading in States, like my own in California, to create legislation to mandate vaccination among children in public schools.

11:55 So parents need to be aware of that.

11:57 Failure to thrive, this is where I’m going to close on our discussion of infants.

12:01 It’s a scary potential diagnosis.

12:04 Yet it remains pretty uncommon.

12:08 There are different definitions, but the most common one used is when the -- I’m sorry, when the weight and the child’s body mass index are lower than the fifth percentile, also, it’s a concern when they cross two major percentile lines for weight.

12:26 And therefore, you can consider using multiple criteria, including their length and their body mass index and their weight together.

12:35 So in terms of causes, the first thing I do when I see a baby with abnormal length or abnormal weight is recheck it.

12:46 That’s right.

12:47 So babies are squirming, and it’s amazing, a few grams make a big difference and can push the baby up or down, over or under a line.

12:57 And so the first thing to do is recheck it when it seems abnormal, and that resolves the problem I’d say about 75% of the time.

13:06 For patients with true failure to thrive as using one of those definitions, just remember that, and this is important for clinical care, as well as exam, that social issues cause the vast majority of cases of failure to thrive and particularly when the child isn’t having a lot of symptoms, mostly respiratory, feeding, or gastrointestinal symptoms, then it’s almost always social issues.

13:31 But you do want to perform lab testing in cases of failure to thrive where you can’t find a social issue at heart there.

13:40 And of course you’re going to refer those kids to a social worker or child protective services because they’re going to be doing investigations within the patient’s home.

13:48 The typical way to start up a workup for failure to thrive with laboratory: CBC, comprehensive metabolic panel, urinalysis and culture, along with the sed rate and a thyroid stimulating hormone.

14:02 But many, many cases don’t even get to there because you’re doing a thorough assessment for those social causes.

14:09 So what we learned today was the schedule of how to see an infant over that first year of life and some of the key questions that parents may have and the key factors for keeping kids well during that time.

14:23 Thanks very much.