Well-baby Care

1. Measure and chart growth parameters, including head circumference, at each assessment; examine appropriate systems at appropriate ages, with the use of an evidence-based pediatric flow sheet such as the Rourke Baby Record.

2. Modify the routine immunization schedule in those patients who require it (e.g., those who are immunocompromised, those who have allergies).

3. Anticipate and advise on breast-feeding issues (e.g., weaning, returning to work, sleep patterns) beyond the newborn period to promote breast-feeding for as long as it is desired.

4. At each assessment, provide parents with anticipatory advice on pertinent issues (e.g., feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues).

5. Ask about family adjustment to the child (e.g., sibling interaction, changing roles of both parents, involvement of extended family).

6. With parents reluctant to vaccinate their children, address the following issues so that they can make an informed decision:

   • their understanding of vaccinations.

   • the consequences of not vaccinating (e.g., congenital rubella, death).

   • the safety of unvaccinated children (e.g., no Third World travel).

7. When recent innovations (e.g., new vaccines) and recommendations (e.g., infant feeding, circumcision) have conflicting, or lack defined, guidelines, discuss this information with parents in an unbiased way to help them arrive at an informed decision.

8. Even when children are growing and developing appropriately, evaluate their nutritional intake (e.g., type, quality, and quantity of foods) to prevent future problems (e.g., anemia, tooth decay), especially in at-risk populations (e.g., the socioeconomicaly disadvantaged, those with voluntarily restricted diets, those with cultural variations)

Routine Visits

• Recommended at 1 week, 2 months, 4 months, 6 months, 12 months, 18 months, 4-5 years

• Ask for risk factors, family history, pregnancy history, delivery history (resuscitation)

• Address parental concerns

Physical Exam

• Height, weight, head circumference (WHO Canadian Growth Chart)

  • Correct percentiles if born <37w until 2-3yo

  • Max 10% weight loss by 4-5d, regain birthweight by 2w

    • 30g/d until 3 mo, 20g/day until 6 mo, 10g/day until 12 mo

    • Double BW by 4mo, triple BW by 1y

• Fontanelles (Posterior closed by 2mo, anterior closed by 18mo)

• Eyes (Red reflex, corneal light reflex, cover-uncover)

• Hearing screen

• Heart, lungs

• Abdomen, umbilicus

• Skin (Jaundice)

• MSK

  • Muscle tone

  • Hip exam until walking

    • 0-3 months: Ortolani, Barlow

    • >3 months: Limited hip abduction, Galeazzi

• Genital

  • Foreskin

  • Testicles

    • Refer if undescended (palpable, ectopic, nonpalpable) at 6 months

      • Consider earlier if ascended testis, bilateral nonpalpable, or associated hypospadias/ambiguous genitalia

      • Ultrasound not recommended as unhelpful

      • Retractile testis can be followed until puberty

Circumcision

• Not routinely recommended

  • Pros:

    • Decrease

      • Penile cancer (NNT 900-322,000)

      • Phimosis (NNT 67)

      • UTI (NNT 111)

      • HPV (NNT 5), HIV (NNT 298), HSV (NNT 16)

    • Decrease cervical cancer and STI in partner

  • Cons:

    • Surgery risks: Infection (NNH 67), bleeding (NNH 67)

    • Meatal stenosis (NNH 10-50)

    • Ethical concerns

  • Contraindicated: Hypospadias

Milk

• Exclusive breastfeeding recommended for first 6 months and continued into second year of life

  • Breastfed babies should receive Vitamin D 400 units PO daily

    • Vitamin D 800 units daily if high risk (limited sun exposure, darker skin, obesity)

  • Express breast milk can refrigerate up to 3d and freeze up to 6mo

    • Warm milk by placing in warm water

• Switch from formula to homogenized milk at 500-750 mL/day at 12 months

  • Discontinue bottle by 18 months

• Transition to 1-2% milk (500mL/day) at 2-3 years

Introducing Food

• No evidence to delay food beyond 6-12 months

  • Introduce foods one at a time q3d (monitor for reactions)

  • Avoid solid round smooth dry/sticky foods risk of choking

  • Avoid sugary food/drinks

• No beets, carrots, spinach, turnips before 6 months (nitrates)

• No honey in first year

• Inquire about vegetarian diets

• Iron-containing foods should be encouraged when introducing solids

  • Iron-fortified cereals and grain products

  • Consider screen at 6-12mo for anemia in at-risk (eg. low SES)

Safe Sleep

• Safe crib (no soft objects/loose items, firm mattress)

• On Back

• Room sharing for <6 months

• Pacifier if <6 months

• Avoid bed sharing (consider bed box)

Swaddling

• Avoid beyond 2 months

• Hip safe swaddling

Car Seats

• Rear-facing car seat

  • Infant must use rear-facing car seat

  • Use a larger seat once baby outgrows infant seat, and keep rear facing until at least 2 years of age or reaches the maximum weight or height limit of the rear-facing seat, as stated by the manufacturer

• Forward-facing car seat with a 5-point harness

  • Once child outgrows larger rear-facing seat and is at least 2 years old, use 5-point harness seat until at least 18kg (40lbs) and can sit straight/tall without moving out of position or unbuckling (this may be 4-6 years old)

• Booster seats with belt-positioning

  • When child has outgrown forward-facing car seat with a 5-point harness, use a booster seat until 145cm (4'9") tall and they safely fit in adult seat belt without slouching (for most children this is 9-12 years old)

• Rear seat with adult seatbelt until 13 years old

Medications

• Acetaminophen 10-15mg/kg/dose q4-6h

• Ibuprofen 4-10mg/kg/dose q6-8h in >6mo

• Avoid OTC medication (especially if using acetaminophen/ibuprofen)

Screen Use (Digital Media)

• No screentime <2yo

• Limit use and encourage meaningful content (educational, active , social)