All right, happy times, let’s talk
about examination of the healthy
infant, nothing like seeing a nice
healthy infant in front of you.
And good care for the
infant actually starts
well before the infant
arrives in your practice.
So first of all,
the waiting room.
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.
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.
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.
So you want to have toys
available like this waiting room
is a good example, seating
appropriate for young kids.
Having stickers goes as long,
long way as to making the
owies feel better and
the kids stop crying.
Very importantly from a medical
side, you’re going to want
to follow weight and height
assiduously in these kids.
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.
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.
And then when it comes show
time to hold that baby down
and do the vaccines, it should
be very, very efficient.
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.
I’ve been very impressed with our personal
pediatrics practice in doing this.
Anything that involves a kid and
maybe it’s a little bit harder
among infants, but you can
still play peekaboo with them.
But I always give it the chance
for young children to manipulate
the stethoscope, understand
it’s not going to be harmful.
Try to make games as you
go along of looking
into the ears, of checking
for the red reflex.
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.
And of course, you need
good communication with the
family because kids can’t
give their own histories.
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.
And then at one month, two months, four
months, six months, nine months, and a year.
So a baby who is born
on January 1st should
have a schedule that looks
something like that.
How about breastfeeding?
Of course, we recommend
breastfeeding, it’s associated
with a lot of health benefits
we’re going to go over.
These might be on
At least the first six months should be
exclusive breastfeeding and a strong
consideration should be paid to continuation
of breastfeeding through one year.
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.
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.
For the mother, there
are also some benefits.
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.
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.
Lower risk of ovarian
and breast cancer
and improved bonding between
mother and infant as well.
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.
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
versus the babies in a nursery,
they should still be checked
by the staff for jaundice.
Transcutaneous bilirubin is
great, it’s noninvasive and
it’s about equally useful
as serum bilirubin levels.
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
but it can occur and it’s devastating,
obviously you want to avoid it.
For patients with rising bilirubin, definitely
get a blood type and a Coombs' test.
Consider G6PD testing, as well,
for glucose-6 phosphate disease
because these children with
jaundice may be at higher risk.
How do you prevent
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.
And once jaundice is identified, that
is non-indication of itself to reduce
breastfeeding, only in severe jaundice
would that be a consideration.
You want to continue
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.
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
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.
Sleep should always be -- the patient
should always be on the back.
So the baby should
always be face up
and that’s to prevent
sudden infant death.
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.
Now we know all those things,
unfortunately, can promote a
higher risk of SIDS, and
therefore, should be eliminated.
So really, it’s just the baby.
They may be swallowed
in a blanket,
but it shouldn’t have any loose
materials within their crib.
Average number, average sleep,
remember, it’s very high.
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.
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.
Do try to tell them
that for most infants,
night waking by age six months is
going to be pretty infrequent.
It’s rare to have a child who’s waking
up two or three times per night.
Usually it’s along the lines of
maybe once or twice per night.
And it’s really hard to recommend one
form of training versus another.
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.
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.
And likewise, you don’t want
to be rushing in to, you know,
every time they’re crying
when they’re 15 months old.
So avoiding the extremes
and kind of keeping it
flexible based on your child’s
condition is important.
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.
What about pacifier use?
That’s a big question as well.
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.
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.
There’s not as many
as there once were.
So really try to wean off the
pacifier, certainly, and you
could start at six months,
that’s perfectly reasonable.
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.
Really try to stay away
from vaccine delays.
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.
Try to keep the kids on schedule,
unless they have a real
contraindication for vaccines
that day, keep them on schedule.
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.
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.
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.
So parents need to
be aware of that.
Failure to thrive, this is where I’m going
to close on our discussion of infants.
It’s a scary
Yet it remains pretty uncommon.
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.
And therefore, you can consider
using multiple criteria, including
their length and their body mass
index and their weight together.
So in terms of causes, the
first thing I do when I see a
baby with abnormal length or
abnormal weight is recheck it.
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.
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.
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.
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.
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.
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.
But many, many cases don’t even
get to there because you’re
doing a thorough assessment
for those social causes.
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.
Thanks very much.