1. Well Child Care 0-12 Months Kellie Ernzen Kruger, M.D. Med-Peds Rounds August 11, 2010 Kellie Ernzen Kruger, M.D. Med-Peds Rounds August 11, 2010

2. The Systematic Approach Aviation Surgery Engineering Industrial operations Litigation Financial planning Event planning Resident to-do lists…

4. Systematic Approaches in Medicine and Pediatrics H&Ps –CC, HPI, PMHx, PSHx, Meds, Allergies, FHx, SHx, ROS, PE, Labs, Studies, Assessment and Plan Admission Orders –ADCVAANDIML EKG interpretation –Rate, Rhythm, Axis, Intervals, Morphology, R wave progression, ST segment changes Chest xray interpretation –ABCDE (Airway, Bones, Cardiac, Diaphgrams, Everything else)

5. A Systematic Approach to Well Child Care Diet Elimination Sleep Development Home School Safety Vaccines Anticipatory Guidance

6. Well Child Care in the First Year Hospital Follow-up 2 weeks 2 months 4 months 6 months 9 months 12 months Use the same systematic approach with every visit!

7. Hospital Follow-up Diet –Breast feeding vs formula –Frequency of feeds – minimum q2-3 hrs, 15 minutes each side or 2-3 oz at every feed –Burping at the end of each feed –Check-in about breast feeding – is mom’s milk in? If possible, observe breastfeeding Elimination –Frequency of wet diapers – minimum 5-6 per day –Bowel movements – minimum 3-4 per day Sleep –Waking at least every 4 hours to feed –Is mom sleeping when baby sleeps? –Does the baby sleep in his own crib/bassinette?

8. Hospital Follow-up Development –Newborn reflexes (Moro, rooting, suck, palmar grasp) Home –Who else lives at home? Other children? How are they adjusting to the new baby? –Tobacco exposure School

9. Hospital Follow-up Safety –Back to sleep, nothing in the crib, rear-facing carseat Vaccines Anticipatory Guidance –Jaundice –Breastfeeding support –Maternal depression screening –Fever precautions/avoiding crowds (relatives, church, etc) –“Normal” newborn things – sneezing, hiccupping

10. Two weeks Diet –Breast feeding vs formula –Frequency of feeds – minimum q2-3 hrs, 15 minutes each side or 2-3 oz at every feed –Burping at the end of each feed –If possible, observe feeding (breast or bottle) Elimination –Frequency of wet diapers – minimum 5-6 per day –Bowel movements – minimum 3-4 per day Sleep –Waking at least every 4 hours to feed –Is mom sleeping when baby sleeps? –Average 16-20 hours sleep per day

11. Two weeks Development –Follows objects to midline Home –Who else lives at home? Other children? How are they adjusting to the new baby? –Tobacco exposure School

12. Two weeks Safety –Back to sleep, nothing in the crib, rear-facing carseat Vaccines Anticipatory Guidance –Weight check –Colic –Maternal depression screening –Fever precautions/avoiding crowds –“Normal” newborn things – sneezing, hiccupping

13. Two months Diet –Breast feeding vs formula –Frequency of feeds – q3-4 hrs, 15 minutes each side or 3-4 oz at every feed –Burping in the middle or at the end of each feed Elimination –Frequency of wet diapers – minimum 5-6 per day –Bowel movements – usually 2-3 per day Sleep –Average 15 hours sleep/day (usually 10 hrs at night) –May sleep 5-6 hours at a time at night, with 2-3 naps during the day

14. Two months Development –Follows objects past midline –Lifts head when lying on stomach Home –Who lives at home? –Tobacco exposure School

15. Two months Safety –Back to sleep, rear-facing carseat Vaccines –DTaP, IPV, HepB (Pediarix) –Hib –PCV13 –Rotavirus Anticipatory Guidance –Tummy time –Colic –Childcare –Reflux

16. Four Months Diet –Breastfeeding/bottle feeding q3-4 hrs –No longer needs a nighttime feeding –Solid foods – one new food per week Begin with cereal – rice, oatmeal, mixed grain Elimination –Stooling – can be 3x/day to once every 3 days, after starting solid foods Sleep –Average 14-16 hours sleep/day, with 2-3 naps –Nighttime sleep routine, e.g. bathtime, reading, rocking, singing, etc

17. Four months Development –Reach for objects –Push up onto his hands when lying on his stomach –Roll from stomach to back –Vocalize “ah-goo” and other vowel-consonant combos Home –Who lives at home? –Tobacco exposure School

18. Four months Safety –Back to sleep, rear-facing carseat Vaccines –DTaP, IPV, HepB (Pediarix) –Hib –PCV13 –Rotavirus Anticipatory Guidance –Rolling –Introduction of solid foods –Stimulation – toys to develop motor skills, reading books

19. Six Months Diet –Solid foods – one new food per week Cereal, then vegetables, then fruits, then meats Work up to eating solids 3 times/day, mimicking mealtimes Continue breastfeeding/formula feeding after solids Elimination Sleep –Cold turkey –Ferber method –Anticipate need for sleep – avoid overtiredness –Be consistent and give it time to work (at least 2 wks)

20. Six months Development –Sit with/without support –Turn in the direction of parents’ voice –Roll from back to stomach –Rake objects into a fist Home –Bathing - change to tub, if able to sit unassisted School

21. Six months Safety –Mobility at home Vaccines –DTaP, IPV, HepB (Pediarix) –Hib –PCV13 –Rotavirus Anticipatory Guidance –Childproofing the house –Sunscreen –Water safety –Teething

22. Nine Months Diet –Three meals a day, with snacks in between Continue breastfeeding/formula feeding after solids Be persistent when it comes to introducing new foods – may need 15-20 attempts –Continue to introduce finger foods –Introduce a sippy cup Elimination Sleep –Transition from 3 naps to 2 naps during the day –Sleep uninterrupted overnight –Consistent nighttime routine

23. Nine months Development –Crawl/creep along the floor –Stand with assistance –Look for dropped objects –Begin using pincer grasp –Babble “mama” and “dada”, though indiscriminately –Separation anxiety –Ages and Stages Developmental Screen Home –Childproofing the house –Teeth brushing School

24. Nine months Safety –Continue rear-facing in car Vaccines –None Anticipatory Guidance –Childproofing the house –Water safety –Sunscreen –Teething

25. Twelve Months Diet –Three meals a day, with snacks in between –Continue with finger foods –Introduce cow’s milk in a cup, to help wean the bottle –Continue breastfeeding as desired Elimination Sleep –Average sleep 13-14 hours/day, with 1 or 2 daytime naps –Sleep uninterrupted overnight –Consistent nighttime routine

26. Twelve months Development –Cruise along furniture –Stand alone –Drink from a sippy cup –Say “mama” or “dada” discriminately –Wave bye-bye Home –Changes in family members/caregivers School –Social interactions – play groups, trips to the park for children not in daycare or school

27. Twelve months Safety –Okay to face forward in the car, at 12 months and minimum 20 lbs (still safer to face backwards) Vaccines –MMR –VZV –Hep A –Hib* –PCV13* Anticipatory Guidance –Water safety –Sunscreen –Discipline and setting limits –Anemia, Lead, TB screening when appropriate

29. What do to about… Vitamin D supplementation? Iron supplementation? Fluoride supplementation?

30. Remember the Systematic Approach! Diet Elimination Sleep Development Home School Safety Vaccines Anticipatory Guidance