Infant Care

Infant care is provided primarily by the child’s parents or other caregiver. A physician can greatly impact the quality of this care during the regularly scheduled outpatient visits, also known as well-child visits. During these visits, the physician has an opportunity to perform a comprehensive assessment of the child’s health, gauge caregivers’ apprehension about their role, and evaluate the overall growth environment of the child. Routine visits should be scheduled at regular intervals, with additional visits for acute concerns. The physician should conduct a history and physical examination; assess growth, development, and nutritional status; encourage administration of vaccinations; and provide anticipatory guidance and counseling to parents or caregivers, making sure to address any questions and concerns and to foster optimal development and support.

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Well-Child Checks

Well-child checks are visits scheduled at crucial ages in a child’s development. These checks are necessary to assess overall health, to provide preventive services, for early detection of disease and abnormalities, and for prompt management of health concerns.

Schedule in the United States

  • 3–5 days after birth
  • 1 month
  • 2 months
  • 4 months
  • 6 months
  • 9 months
  • 12 months
  • Yearly
Exam schedule for a newborn baby

Schedule for a baby born on January 1
B: birth
E: exam

Image by Lecturio.

Components of the well-child check

  • History and physical exam:
    • General: assess alertness, tone, vigor
    • Ocular: assess red reflex, symmetry, and motility
    • Cardiac: assess for presence of new murmurs or rhythm/rate disturbances
    • Abdomen: assess for palpable masses or hernias
    • Musculoskeletal: assess for developmental dysplasia of the hips (neonate), appropriate strength, and range of motion
    • Neurologic: ensure appropriate resolution of primitive reflexes
    • Skin: assess coloration and check for any skin lesions
  • Height and weight:
    • Should be measured at every visit, with the same instruments if possible, and plotted on a growth chart
    • Monitoring pattern of growth along plotted curves is more important than the absolute value.
    • Significant deviations (> 2 standard deviations) from the plotted curve (change in growth patterns) are worrisome and require further evaluation.
  • Head circumference measurement:
    • Should also be plotted and monitored on growth chart
    • Increasing head circumference > 97th percentile for age is a concern for hydrocephalus or tumor.
    • Decreasing head circumference (microcephaly) < 3rd percentile for given age is a concern for possible congenital TORCH (toxoplasmosis, other agents, rubella, cytomegalovirus, herpes simplex) infections
  • Assessment of feeding/nutritional status:
    • Discuss frequency, amount, and type of feedings.
    • For breastfeeding infants, adequacy of latch and positioning during feeds, perceived effectiveness of feeds, and concerns or challenges should be addressed at each visit.
    • Offer guidance; offer skilled breastfeeding support services, if needed.
    • At 4–6 months, provide advice regarding transition to solid foods.
  • Assessment of developmental milestones
  • Immunizations
  • Additional screenings
  • Providing anticipatory guidance and counseling to parents
  • Addressing any parental/caregiver concerns
WHO Growth charts for boys in Canada

Growth charts:
Height and weight should be recorded at every well-child visit (head circumference until 3 years old). The results are plotted on standardized growth charts to monitor growth progression along percentile lines.

Image: “2010 WHO Growth Charts for Canada and CPEG Growth Charts for Canada” by Section of Pediatric Endocrinology, Children’s Hospital of Winnipeg, FW 302-685 William Ave, Winnipeg, MB R3E 0Z2, Canada. License: CC BY 2.0

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Feeding and Nutrition

General feeding guidelines

  • Feedings should occur on demand or approximately every 2–3 hours; 8–12 per day.
  • A feeding typically lasts 20 minutes.
  • Hold baby while feeding; do not prop bottle if bottle feeding.
  • Do not microwave either expressed or formula milk, as this can lead to scalding due to inconsistent temperatures throughout.

Breastfeeding

Breastfeeding is the primary source of nutrition for infants and is recommended as the exclusive means of feeding for the 1st 6 months of life, with continuation up to 2 years of age.

Mature human milk contains necessary nutrients for infant and provides antibodies formed by the mother, protecting the baby against infections as the immune system develops.

Benefits to infant:

  • Breast milk immunoglobulins confer passive immunity to the infant to risk of infections
  • Improves GI function and motility
  • Risk of asthma, allergies, obesity, diabetes, and SIDS

Benefits to mother:

  • Increases maternal–baby bonding
  • Faster uterine constriction
  • ↓ Risk of ovarian and breast cancer
  • Faster maternal weight loss
  • Method of contraception

Breast milk storage:

  • Room temperature (approximately 77°F): ≤ 4 hours
  • Refrigerator: ≤ 4 days
  • Freezer: 6 months best; up to 12 months acceptable

If there are challenges with breastfeeding, expressed breast milk should be given to infant.

Breastfed infants should not be encouraged to drink formula except in the following situations:

  • Breast milk production inadequate
  • Infant showing signs of dehydration, such as decreased urine output (may indicate inadequate milk intake)
  • Contraindications to breastfeeding exist:
    • Maternal: certain infections (e.g., HIV and TB) and use of substances or medications that can be passed through the breast milk
    • Infant: certain inborn errors of metabolism (e.g., galactosemia, phenylketonuria)
Breastfeeding infant

Breastfeeding an infant

Image: “Breastfeeding infant” by Ken Hammond. License: Public Domain

Formula feeding

If an infant is formula-fed, it is important to discuss the type of formula used:

  • Milk-based formula: most common and 1st-line choice
  • Soy-based formula: also an option, but no real benefit to its use over milk-based formula
  • Special hydrolyzed formulas (e.g., alimentum): may be used for those with a true milk-protein allergy
  • High level of cross-allergy between milk-based and soy-based formulas: if true milk allergy exists, should not use soy-based formula

Appropriate mixing and ratio of powdered formula to water should be reviewed.

Additional nutritional counseling

  • Supplementation
    • Vitamin D supplements in breastfed infants 
    • Daily iron supplements for infants < 6 months of age who were born prematurely
    • Fluoride supplementation in infants ≥ 6 months of age if local water supply has inadequate fluoridation
  • May start introducing solid foods gradually beginning at approximately 4–6 months of age
    • Rice cereal fortified with iron is the recommended initial weaning food. 
    • Only 1 new food per week should be introduced to an infant’s diet to help easily identify any potential food allergies.
  • Do not give cow’s milk before 1 year of age.
  • Honey should not be given to infants < 1 year of age because of the risk of botulism.

Development 0–12 Months

Growth parameters

  • Weight 
    • Double birth weight by 4 months 
    • Triple birth weight by 1 year 
  • Length/height
    • Should increase by > 30% relative to birth length by 6 months of age
    • Should increase by approximately 50% relative to birth length by 1 year of age
  • Rate of head circumference growth
    • Growth greatest in 1st 3 months of life (approximately 5 cm)
    • Gradually slows by 12 months of age, with rate falling to approximately 1 cm between 9 and 12 months of age
  • Inadequate growth in these parameters for age (failure to thrive) requires further evaluation of underlying conditions:
    • Problems with feeding
    • Possible neglect
    • Pathologic conditions affecting nutrient absorption
    • Conditions causing excessive calorie loss

Developmental milestones

  • Markers or milestones set at specific ages to assess for appropriate development in infants and children in the following areas: 
    • Gross motor skills
    • Fine motor skills
    • Language development
    • Social skills
    • Cognitive skills
  • Represent what is expected on average:
    • Length of time each child requires to meet milestones varies. 
    • When a child does not meet a milestone, it should be noted, but may not be of immediate concern.
    • Persistent delay or global lack of achievement of milestones longer than expected may warrant further evaluation and extra support and referrals to help the child develop abilities and skills properly.
    • In cases of developmental delay, the earlier the intervention, the better the final outcome for the child.
  • Developmental red flags:
    • Primitive reflexes persist > 6 months of age.
    • Predominant use of only 1 hand (right-/left-handedness) < 12 months of age
Table: Developmental milestones during the 1st year of life
AgeGross motorFine motorLanguageSocial/cognitive
1 month
  • Turns head while supine
  • Lift heads while prone
Hands clenched in fists brought near face most of the timeMakes sounds
  • Responds differently to caregiver’s voice
  • Startled by loud noises
2 months
  • Holds head and chest up while prone
  • Has very brief head control while sitting up
  • Hands not fisted half the time
  • Clasps hands
  • Coos
  • Vowel sounds
  • Social smile
  • Recognizes caregiver
4 months
  • Sits with trunk support
  • Rolls prone to supine
  • Pushes up on wrists
  • Loss of head lag when pulled from prone
  • Hands open most of the time
  • Reaches and clutches consistently
  • Grasps items
  • Laughs loudly
  • Turns to voice
  • Stops crying at soothing voice
  • Looks around
  • Mouths objects
  • Spends more time looking at strange faces as opposed to familiar ones
5 months
  • Sits with pelvic support
  • Rolls supine to prone
  • Palmar grasp
  • Can transfer objects (e.g., hand to mouth to hand)
  • Says “ah-goo”
  • Razzes, squeals
  • Begins to respond to name
  • Expresses anger in a way other than crying
  • Recognizes caregiver visually
  • Can turn head to look for dropped objects
  • Forms attachment to caregiver
6 monthsSits for brief moment propped on hands
  • Can transfer objects (hand to hand)
  • While holding object in one hand, takes 2nd object in other hand
  • Rakes small items
  • Babbles with consonants
  • Stops momentarily at hearing “no”
  • May gesture to be picked up
Stranger anxiety
7 monthsSits steadily without supportGrasps using side of hand (radial–palmar grasp)
  • Looks toward familiar object when named
  • Increased syllable variety when babbling
  • Explores different aspects of a toy
  • Finds partially hidden objects
9 months
  • Pulls to stand
  • Crawls on 4 straightened limbs
Grasps with 2 fingers and thumb below (radial–digital or 3-finger grasp)
  • Says “mama” (nonspecific)
  • Nonreduplicating babble
  • Imitates sounds
  • Can use sound to get attention
  • Object permanence
10 months
  • Cruises around furniture with 2 hands
  • Stands with 1 hand held
  • Walks with both hands held
Grasps pellet with side of index finger and thumb (inferior pincer grasp)Says “dada” (specific)
  • Waves “bye-bye”
  • Plays peekaboo
12 monthsTakes 1st independent steps (walk might be delayed up to 18 months)
  • Fine pincer grasp
  • Builds tower of 2 cubes*
  • Throws objects
Says at least 1 word other than “dada” or “mama”
  • Comes when called
  • Follows 1-step command with gestures
*Number of cubes with which a child can build a tower = child age/2

Immunizations

  • Multiple vaccinations are routinely recommended for infants.
  • Combination vaccines often used to reduce the number of injections given
  • Vaccines are typically administered IM or SC, except for rotavirus vaccine, which is administered orally.
  • If vaccinations are missed:
    • Catch-up schedules: reduced time interval needed between vaccine doses
    • Do not have to start series over if it was already started
Table: When do children need vaccinations?
Birth1 month2 months4 months6 months9 months12 months
Hepatitis B1st dose2nd dose← 3rd dose →
Rotavirus
Rotarix RV1 (2-dose series); RotaTeq RV5 (3-dose series)
1st dose2nd dose3rd dose (RV5)
Diphtheria, tetanus, & acellular pertussis (DTaP: < 7 yrs)1st dose2nd dose3rd dose
Haemophilus influenzae type b (Hib)1st dose2nd dose3rd doseBooster →
Pneumococcal conjugate (PCV13)1st dose2nd dose3rd dose← 4th dose →
Inactivated poliovirus (IPV: < 18 years)1st dose2nd dose← 3rd dose →
Influenza (IIV)Annual vaccination →
Measles, mumps, rubella (MMR)1st dose →
Varicella (VAR)1st dose →
Hepatitis A1st dose →
Vaccination schedule:
Well-child visits are also opportunities to provide age-appropriate vaccinations according to recommended schedules. The timing of the vaccination is based on the age at which the child is most vulnerable to and most likely to encounter the disease. Vaccine schedules are updated annually, but the schedule in the table shows when vaccinations are routinely given in the United States.

Health Screenings

  • Hearing screening: 
    • Should be performed before discharge at birth
    • No later than 1 month of age if missed in the hospital
  • Visual acuity screening: performed at least once between 3 and 5 years of age
  • Iron deficiency anemia:
    • Risk assessment along with testing serum hemoglobin and hematocrit
    • Recommendation is to test once between 9 and 12 months of age
  • Lead: Test serum lead levels in all infants.
    • Initial screen at 12 months if low risk, 6 months if high risk
    • Lead exposure can lead to permanent neurologic damage.

Acute Concerns

Caregivers should be counseled to seek further evaluation immediately if any of the following signs or symptoms occur.

  • Rectal temperature > 38°C (100.4°F) in an infant < 57 days
  • Rectal temperature > 38.5°C (101.3°F) in an infant ≥ 57 days 
  • Decreased alertness:
    • Persistently decreased feeding
    • Lethargy, sleeping more than usual and not easily awakened
  • Absence of tears while crying (sign of dehydration)
  • No wet diapers > 6 hours
  • Difficulty breathing: 
    • Increased rate of respirations
    • Use of accessory muscles of breathing
    • Noisy breathing
  • Changes in skin coloration: 
    • Bluish tint (cyanosis)
    • Yellowing of the skin (jaundice)
    • New rash
    • New bruising
  • Irritability: persistently crying inconsolably
  • Has a seizure
  • Vomiting > 24 hours, forceful/projectile vomiting, or vomit that contains blood or bile (green coloration)
  • Diarrhea: 
    • > 8 stools in 8 hours
    • Stools contain blood, pus, or mucus.
  • Nonbreastfeeding infant does not have bowel movement for > 3 days, especially if accompanied by vomiting or irritability

Anticipatory Guidance and Counseling

Sleep

  • Always on back and avoid blankets/toys/bumpers to reduce the risk of SIDS
  • Sleep pattern and duration:
    • 14–17 hours/day for newborns
    • 12–15 hours/day for infants
    • Infrequent night waking by age 6 months
    • Emphasize bedtime routine

Umbilical cord care

  • Keep stump clean and dry; use water and gauze only.
  • Stump usually falls off within 2–3 weeks.
  • Monitor for signs of infection: localized redness, swelling, tenderness, odor, and/or yellowish discharge from the stump
  • Bleeding may occur if stump is pulled or tugged off rather than falling off naturally.
  • Sometimes a moist, pink or red lump of tissue may develop (granuloma) at the umbilicus and drain yellowish fluid.
    • Umbilical granuloma is the most common cause of an umbilical mass.
    • Most common treatment is with silver nitrate.
    • Alternative treatment is in-office ligation with sutures.
Baby with umbilical cord stump

A day-old baby with its cord stump still attached

Image: “A day-old baby with its cord stump still attached” by Evan-Amos. License: Public Domain

Diaper rash prevention

  • Diaper rash typically results from irritation, bacterial infection, or yeast infection.
  • Watch for redness, scaliness, sores, or blisters in buttock and genital area under the diaper.
  • Tips to prevent and treat diaper rash:
    • Keep skin clean and dry.
    • Change diaper as soon as possible after urination or passing of stool.
    • Do not use wipes that contain alcohol or scents. 
    • Diapers should be loose, not overly tightened, to allow for airflow.
    • Place baby on towel and allow for bare bottom diaper-free time to expose skin to air. 
    • Consider barrier ointments with zinc oxide or petroleum jelly base.
Irritant diaper dermatitis

Mild benign diaper rash in breastfed, cloth-diapered male infant 3 weeks of age

Image: “Irritant diaper dermatitis” by Dailyboth. License: CC0 1.0

Pacifier use

  • Reduces the risk of SIDS through 6 months
  • Increases the risk of otitis media and wheezing
  • Weaning should start at 6 months

Infant safety

  • Car-seat installation
    • Car seats should be placed in rear of the vehicle and should be rear-facing until the child is ≥ 20 lb and ≥ 1 year of age.
    • Car seat should not be placed in a seat with an airbag. 
  • Keep water temperature set to < 110°F (43°C) to prevent accidental scalding.
  • Remove firearms from the home.
  • Keep up smoke and carbon monoxide alarms.
  • Concerns for abuse/neglect: Signs on exam and a history that does match physical findings should raise suspicion for abuse or neglect.
    • Multiple injuries in various stages of healing
    • Bruises in odd places in an infant who is not yet mobile
    • Patterned injuries, such as might occur with cigarette or immersion burns
    • Presence of retinal hemorrhage
    • Presence of metaphyseal “bucket handle” or “corner” fractures

Other

  • 1st dental visit should occur after 1st tooth erupts or no later than 12 months of age.
  • Female infants may have blood-tinged or milky-white vaginal discharge in 1st week of life, this is normal because of maternal hormonal withdrawal, but it often concerns parents.
  • Recommendations for “time outs” for parents, so they do not become overwhelmed

Clinical Relevance

The following conditions are relevant to those seen in the course of providing infant care. 

  • Failure to thrive (FTT): suboptimal weight gain and growth in a child. Causes of FTT may be organic or nonorganic, with the majority of cases due to inadequate caloric intake. History and physical examination guides workup, which helps uncover the underlying cause. A multidisciplinary approach is taken in the management of nonorganic causes of FTT, while organic causes require management of the underlying pathologic process. It is important to recognize and treat FTT in order to avoid developmental delays.
  • Colic: persistent and intense paroxysmal crying and fussiness in a healthy infant for no apparent reason that tends to occur in the late afternoons or evenings. Infant cries > 3 hours a day > 3 days a week for > 3 weeks. The etiology of colic is unclear. Colic occurs most often in the 1st few months of life, with spontaneous resolution by 4 months. History and exam leads to diagnosis. Management involves parental reassurance and soothing techniques.  
  • Jaundice of the newborn: may be due to indirect hyperbilirubinemia (physiologic), direct hyperbilirubinemia (pathologic), or breast milk. Symptoms include worsening yellowish discoloration of the eyes and skin. Those with pathologic jaundice may have hepatomegaly, lethargy, and poor feeding as well. Pathologic jaundice often presents in the 1st 24 hours of life. Physiologic jaundice presents within 36–48 hours of life and typically resolves by the 10th day of life. Breast milk jaundice presents in the 2nd–3rd weeks of life. Management involves UV phototherapy and, in severe cases, exchange transfusions. 
  • Developmental dysplasia of the hip: disorder of the hip joint characterized by hip instability, resulting in subluxation or dislocation of the hip. Hip laxity, decreased motion, or leg asymmetry may be noted on exam. Developmental dysplasia of the hip most commonly occurs in otherwise healthy girls and often does not have an identifiable cause. Imaging aids in diagnosis. Treatment of infants ≤ 6 months often involves a Pavlik harness, whereas children > 6 months of age often require open or closed surgical reduction.
  • Febrile illness: most commonly due to urinary tract infections (UTIs), bacterial sepsis, meningitis, and pneumonia in infants < 2 months of age. Lethargy and poor feeding are common. Depending on age of the infant, workup includes CBC, blood culture, urinalysis/urine culture, lumbar puncture, and x-rays. Febrile infants < 30 days old are at high risk for neonatal sepsis and require full workup, admission, and IV antibiotics. The younger the infant, the more extensive the workup needed. 
  • Respiratory syncytial virus (RSV): leading cause of bronchiolitis and viral pneumonia in infants and young children. Respiratory syncytial virus is a frequent cause of hospitalization in infants. Infants may present with cough, wheezing, difficulty breathing, irritability, lethargy, and poor feeding. Diagnosis is clinical; usefulness of nasopharyngeal PCR testing and chest x-ray is questionable, but these may help confirm cases. Management is supportive, including oxygen, nasogastric tube feeding, and mechanical ventilation in severe cases. 
  • Croup: also known as laryngotracheobronchitis. Croup is a common respiratory condition in infants and young children. Croup is caused by a variety of viruses, the most common being parainfluenza virus. Clinical presentation includes low-grade fever, inspiratory stridor, barking cough, and noisy or labored breathing. Diagnosis is usually made via history and exam. Management involves racemic epinephrine and dexamethasone. 
  • Red reflex abnormalities: assessing for the red reflex, or reflection of the eyes, is an important aspect of the infant exam for early detection of potentially vision or life-threatening conditions such as cataracts, retinoblastoma, or other ocular abnormalities. The red reflex is tested in a dark room with an ophthalmoscope and should be present and symmetric in both eyes. If the red reflex is asymmetric or absent or if dark or white spots are seen, referral to a pediatric ophthalmologist should be made.
Jaundice phototherapy

Neonatal jaundice in a newborn undergoing phototherapy

Image: “Jaundice phototherapy” by Martin Pot. License: CC BY 3.0

References

  1. National Collaborating Centre for Primary Care (UK). (2006). Postnatal care: routine postnatal care of women and their babies. Royal College of General Practitioners (UK). (NICE Clinical Guidelines, No. 37.) Retrieved February 23, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK55925/
  2. Drutz, J. E. (2020). Standard immunizations for children and adolescents: overview. UpToDate. Retrieved February 23, 2020, from https://www.uptodate.com/contents/overview-of-the-routine-management-of-the-healthy-newborn-infant
  3. Aites, J., Schonwald, A. (2020). Developmental-behavioral surveillance and screening in primary care. UpToDate. Retrieved February 23, 2020, from https://www.uptodate.com/contents/developmental-behavioral-surveillance-and-screening-in-primary-care
  4. When your baby or infant has a fever. (2019). MedlinePlus. Retrieved February 23, 2020, from https://medlineplus.gov/ency/patientinstructions/000319.htm
  5. Diarrhea in infants. (2019). MedlinePlus. Retrieved February 23, 2020, from https://medlineplus.gov/ency/patientinstructions/000691.htm
  6. Infant vomiting. (2015). HealthChildren.org (American Academy of Pediatrics). Retrieved February 23, 2020, from https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Infant-Vomiting.aspx
  7. Constipation in infants and children. (2018). MedlinePlus. Retrieved February 23, 2020, from https://medlineplus.gov/ency/article/003125.htm
  8. Umbilical cord care in newborns. (2019). MedlinePlus. Retrieved February 23, 2020, from https://medlineplus.gov/ency/article/001926.htm
  9. Palazzi, D. L., Brandt, M. L. (2020). Care of the umbilicus and management of umbilical disorders. UpToDate. Retrieved February 23, 2020, from https://www.uptodate.com/contents/care-of-the-umbilicus-and-management-of-umbilical-disorders
  10. Diaper rash. (2019). MedlinePlus. Retrieved February 24, 2021, from https://medlineplus.gov/ency/article/000964.htm
  11. Le, T., Bhushan, V., Grow, R. W., Tache, V. (2008). First aid for the USMLE Step 3, 2nd ed. McGraw-Hill. 
  12. Red reflex examination in neonates, infants, and children. (2008). Pediatrics. American Academy of Pediatrics. Retrieved February 23, 2020, from https://pediatrics.aappublications.org/content/122/6/1401

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