Chapter 16 The Newborn Well Child Visit

Speaking Intelligently

The first newborn visit ideally occurs within a few days after hospital discharge.¹ I first congratulate the parents and then elicit their questions and concerns. The infant is carefully evaluated for jaundice. If the infant is breastfeeding, determine if the mother’s milk is in and if the baby is feeding well and gaining weight. Establishment of successful feeding and weight gain is marked by return to birth weight by 10 to 14 days of age for breastfed and formula-fed infants. All prenatal data, including ultrasounds, are reviewed, and any needed follow-up is arranged.

Medical Knowledge and Patient Care

History

The first newborn office visit is comprehensive and may require more time and organization than subsequent infant well visits.¹ Ask the parents, especially first-time parents, how they are adjusting to caring for their newborn. Asking if they have questions or concerns will guide the visit.

Prenatal. The prenatal history and testing, as well as newborn nursery data, should be reviewed with the parents. Were there any complications, such as gestational diabetes or hypertension? Review maternal laboratory results: gonorrhea, chlamydia, syphilis, hepatitis B, group B streptococcus, and human immunodeficiency virus (HIV). Is there a maternal history of genital herpes? Review time of diagnosis and treatment. Were prenatal tests done, such as chorionic villus sampling (CVS), amniocentesis, or fetal ultrasound? Inquire about drug and alcohol use, cigarette smoking, and use of over-the-counter, prescription, or herbal medications.

Birth History. Review the birth history, including duration of labor, method of delivery, and any signs of fetal distress (e.g., meconium-stained amniotic fluid, low scalp pH). Review the Apgar scores. Was any resuscitation performed? Was the infant in the term nursery or the neonatal intensive care unit? Review the birth and discharge weights, length, and head circumference. Note percentiles, and compare with present measurements. Has the infant gained weight since discharge? It is not unusual for a neonate to lose up to 10% of birth weight in the first 2 to 3 days, after which a gain of 20 to 30 g per day is expected. Obtain the newborn screen results. Most states have a mandatory newborn hearing screening program (see Chapter 58, Newborn Hearing Screen). All infants should be assessed for jaundice before discharge. Some infants may have transcutaneous or serum bilirubin assessment, along with prompt outpatient follow-up for ongoing surveillance and management (see Chapter 60, Jaundice). Check if the first hepatitis B vaccine was administered.

Family History. Obtain a thorough family history. Note any hereditary conditions (e.g., sickle cell disease, metabolic defects), birth anomalies, any infant death, and mental health disorders. Social history should include the educational level and occupation of the parents, who lives in the household with the baby, and who will be the primary care provider(s). Ask about environmental tobacco smoke exposure.

Nutrition. Next, obtain information specific to the newborn. Starting with nutrition, is the baby breastfed or bottle fed? If breastfed, there is colostrum for the first few days before the milk comes in.¹ Breastfeeding every 1 to 3 hours for 15 to 30 minutes on one or both breasts is not unusual (see Chapter 56, Infant Feeding) Remind the new mother that the amount of breast milk produced depends on how often the baby feeds—more feeding yields more subsequent milk production—that is, production matches demand. A lactation consultant can be quite helpful if there is difficulty establishing successful feeding. The newborn will require careful monitoring of weight and possible supplementation with infant formula to prevent excessive weight loss and dehydration. Breast milk contains little vitamin D, and hence daily supplementation is recommended. Check any maternal medication for compatibility with breastfeeding. There are multiple options for the formula-fed infant, with milk- and soy-based formulas most common. These are available in powder, concentrate, and ready to feed forms. Review the type of formula and method of preparation, ensuring that the correct amount of water is used. Note that neither the water nor bottles require sterilization. Formula-fed babies usually feed every 3 to 4 hours, initially taking

ounce per feeding and gradually increasing to about 4 to 6 ounces every 3 to 4 hours by 2 months of age. The newborn should not be given any plain water or food.