Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-1068A (07/08)

STATE OF WISCONSIN Reprinted and adapted with permission from Memee K. Chun, M.D.

GENERAL PEDIATRIC CLINIC / 3 ­ 4 WEEK VISIT
(See 2nd page for Anticipatory Guidance for 3 ­4 Week Visit) Completion of this form is voluntary.

Patient Name Accompanied by
Parental Concerns

Date of Birth

Sex

Age

Height

Weight

Birth Weight

Today's Date

Head Circumference
Alertness Activity

Pertinent Perinatal History (see Perinatal visit)

Response To Examiner Note....Present (+) or Absent (-) as Appropriate (Cross off parts not examined or not applicable)

Feeding: Breast _________ x/day, ______________ hours Formula: Type ___________________________________ Amount / Feeding _________________ oz. x/day _________ Water Given _____________________________________ Sleeping Pattern

Part
Skin: Color, texture, birthmarks (location & Size) Head: Shape, Ant. fontanel size Eyes: Lids, pupils, tear ducts, red reflex Ears: Shape, canals, tympanic membranes Nose: Air flow, nares Mouth: Gums, tongue, frenulum, palate Throat: Uvula, pharynx Neck: Position, movement, thyroid Chest: Symmetry of movement, clavicals, sternum Heart: Rhythm, S1, S2, Tones, murmur Lungs: Breath sounds Abdomen: Contour, umbilicus, LSK Extremities: Range of motion of arms and legs Hips ­ abduction, leg length, click, gluteal folds Genitourinary: Urinary stream, vagina, testes Neuromuscular: Tone, posture, head control, fisting Reflexes: Moro ( ) Suck ( ) Root ( ) Tonic neck ( ) Stepping ( ) Palmar grasp ( ) Plantar grasp ( ) Babinski ( ) Placing ( ) Ankle jerk ( )

Skin Condition

Umbilicus

Stool Pattern

Parents' description of baby's temperament Crying, activity, mood, reaction to new situations

Pertinent Family History

Describe Abnormal findings.

Problems Identified and Reviewed

Developmental Observations NO. = Not Observed by parents or R. O. NO. examiners, R. = Reported, O.= Observed
G.M. F.M. LANG. Baby Prone, Lifts and Turns Head Baby Prone, Head Up 45 Eyes Follow Object or Person to Midline Eyes Follow Object or Person Past Midline Quiets in Response to Voice or Noise Vocalizes Spontaneously Vocalizes Responsively Seeks Eye Contact Smiles Responsively Smiles Spontaneously

Neonatal Screen Checked Physical and Emotional Status P.S.

Diet: Vitamins, fluoride, frequency of feedings Anticipatory Guidance: Clothing, breathing, crying, outings, look for response to noise. Holding baby: Mom knows or shown. Use of bulb syringe for nose: Mom knows or shown. Temperature taking: Mom knows or shown. Safety: falls, cribsides, sibs feeding baby, car seat, care while bathing. Home water temperature. Immunization plan.

Parents' Interactions with Baby NO. = Not observed Here O. NO. O. = Observed M = Mother F = Father
Makes Eye Contact With Baby Talks to Baby Changes Position of Baby Frequently Bounces or Pats Baby (Baby Quiet) Responds Only to Baby's Crying Sits Back During Exam

Other Observations

_____________________________
SIGNATURE ­ Provider
Return to clinic in _____ months.

______________
Date Signed
Development and Parent-Child Interactions

HealthCheck General Pediatric Clinic / 3 ­ 4 Week Visit F-1068A (07/08)

Anticipatory Guidance for 3-4 Week Visit Page 2

Diet Vitamins are present in all formulas. For breast fed babies, the need for Vitamin C, D is debatable. Fluoride: formula using water to mix (Madison water 1 ppm), 7 ounces H2O sufficient for newborn dose of 0.25 mg/day. Ready mix formula may need fluoride supplement. Breast-fed babies are given fluoride drops alone or with vitamins. Frequency of feedings ­ Encourage parents to try to feed baby on a regular 2 ½ to 4 hour schedule. Warn the mother that the baby may go through periods when they want more frequent feedings. Usually the bottle-fed baby expresses the same need by emptying the bottle. There is a need for more milk and the breast milk supply will adjust after a few days and the baby will be back on schedule. Anticipatory Guidance Clothing ­ Basic cotton shirt and diaper, add as necessary. Most babies don't need more clothes than average adult. Find out by feeling baby's body, it should be warm but not hot. No tight clothing with long strings, cover hands and feet, especially if the baby scratches. Allow room to kick. Blankets useful at this age but will be kicked off as the baby moves more. Breathing ­ Noisy, irregular at times in most babies. They do stop for several seconds often but should not turn blue!! Sneezing ­ see perinatal discharge Plan Crying ­ reinforce trying to recognize several types of crying. 1. Discomfort 2. Hunger ­ time to eat 3. Tired ­ wants to go to sleep 4. Distress, startle-loud noise or sudden movements Outings ­ baby can go with parents. Shield from excess sun, cold, or wind. May use cotton cloth over face if very windy or cold outside. Look for response to noise. Babies respond to touch, sound and sight. Often loud noises are accompanied by vibrations, e.g., clap, slamming door, footsteps. To test for pure sound, the parents should use their voices while out of baby's sight. As baby gets used to their voice preceding cuddling and feeding, they will start responding to the voice. Holding baby ­ Some first time parents do not know how to hold the baby. Actually, any way they (parents and child) are comfortable and the baby is firmly held is okay. Use of Bulb This is usually given to the parents on discharge from the hospital. It is used to suction mucus from the nares and front parts of the nasal passage only. At birth, this was used to suction the mouth and nose, however at this age, in a normal baby, the swallowing reflex is strong and there is no need to suction the mouth. When the baby has a nasal discharge, it often dries in the nares, causing noisy breathing and some blockage too. Suctioning may remove this mucus. Adding salt water may make this procedure easier. Salt water is made at home by adding ¼ tsp. of salt to 8 ounces of very hot water. After dissolving, it can be used at room temperature and stored for 24 hours. One to two drops in each nare is usually sufficient. Most babies strongly dislike anything in their nose, especially iatrogenic. Use only if the nasal discharge is causing baby to stop nursing or waking up frequently.

Temperature Taking In the nursery, the mother has been shown how to take an axillary temperature. The baby has to be held with the arm close to the body and the thermometer left there 3 to 5 minutes. It is not easily accomplished as the baby gets older. Rectal temperature is the most accurate at this age and not painful at all. The baby is laid on their stomach on the bed or parent's lap, the thermometer inserted ½ to 1 inch (with jelly or vaseline) and left for one minute. The parent should hold the buttocks together around the thermometer. The risk of breaking occurs if the thermometer is held tightly and the baby moves. Safety ­ Falls, Cribsides Newborn babies do wiggle around and will move from one end of the crib to the other. Frequently they move forward on their stomach and stop when the head touches the crib padding. It is necessary to tell this to the parents and warn them not to leave the baby in the crib without the side up. A bumper pad (with bright colors or pattern) should cover the lower end of the crib well. On a changing table, always keep one hand on the baby when reaching for something. Tables are especially dangerous since most are smooth surfaced and allow more mobility. Sibs Feeding Baby This depends greatly on the age of the sib. Definitely not under 3 years and all others should be closely supervised. Water is the safest to feed and this task can be used to help the sib accept the baby. Car Seat Review information given in perinatal period. Encourage and praise proper use of the car seat and reassure that the baby's back will not be damaged. If a long trip is contemplated, suggest they stop every 2+ hours, take the baby out of the seat, feed, lay flat, etc. for short periods. Care while Bathing Parents should have had demonstration and practice bath at the hospital. Until mom feels strong again, she can sponge-bathe the baby. The first bath may be very smooth or the baby may balk strongly at this new activity and thus upset the parents. Discuss the baby's temperament and reassure the parents that: 1) the baby will tolerate it, if introduced slowly, 2) the baby does not have to have a bath everyday, more like every 2 to 3 days plus wiping in between, 3) soap all over is not necessary and makes the task harder, and 4) any way the parents want to bathe the baby, even shower with the parent is fine as long as baby and parents are happy. Caution: Always feel the water temperature before bath or shower. House Water Temperature Review the dangers of hot water. If there are no other children in the house, the parents can delay in turning the water temperature down for a few more months. Immunizations Discuss what will be given at the next visit. If parents show interest, give them handout, otherwise outline the immunization plan.