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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 3: Resuscitate newborns according to current guidelines. Skill: Clinical Reasoning, Psychomotor Skills/Procedure Skills Phase: Treatment Key Feature 4: Maintain neonatal resuscitation skills if appropriate for your practice. Skill: Professionalism Phase: Treatment I took the Neonatal Resuscitation Program about one year ago now, but I don't plan to renew this course as I do not see myself doing obstetrics once I have finished residency. However, on my pediatric nursery rotation, I have had the opportunity to put these skills to use. Currently, the most up-to-date neonatal resuscitation algorithm at this time is as follows:  Team Briefing: If the infant's expected gestational age is not less than or equal to 35 weeks, or if there is expected to be more than one infant, and if there are any risk factors for or signs of fetal distress (ex: meconium fluid), then a clinician skilled in neonatal resuscitation should be present in the delivery room specifically to provide care for the high-risk infant. Equipment checklist:  How to perform resuscitation maneuvers, if indicated:
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Key Feature 1: When examining a newborn, systematically look for subtle congenital anomalies (ex: ear abnormalities, sacral dimple) as they may be associated with other anomalies and genetic syndromes.
Skill: Clinical Reasoning Phase: Hypothesis generation, Physical My approach to the healthy newborn exam, informed by the UpToDate article "Assessment of the newborn infant," is as follows. Note that any signs of abnormalities warrants a more exhaustive assessment.
Newborn
Key Feature 5: When a parent elects to bottle feed, support their decision in a non-judgemental manner. Skill: Professionalism, Patient Centered Phase: Treatment Well-baby Care Key Feature 3: Anticipate and advise on breast-feeding issues (ex: weaning, returning to work, sleep patterns) beyond the newborn period to promote breast-feeding for as long as it is desired. Skill: Clinical Reasoning, Patient Centered Phase: Hypothesis generation, Treatment According to the Evidence Summary of my fave Rourke Baby Record (RBR), "Exclusive breastfeeding is recommended for the first six months of life for healthy term infants. Introduction of solids should be led by the infant’s signs of readiness – a few weeks before to just after 6 months. Breast milk is the optimal food for infants, and breastfeeding (with complementary foods) may continue for up to two years and beyond unless contraindicated. Breastfeeding reduces gastrointestinal and respiratory infections and helps to protect against SIDS." This Evidence Summary also provides a link to an article published by the Canadian Pediatric Society titled, "Weaning from the breast." The abstract for this article concurs with and elaborates on the above quote from the RBR, and includes the following text: "Exclusive breastfeeding provides optimal nutrition for infants until they are six months old. After six months, infants require complementary foods to meet their nutritional needs. This is when weaning begins. Weaning is the gradual process of introducing complementary foods to an infant’s diet while continuing to breastfeed. There is no universally accepted or scientifically proven time when all breastfeeding must stop. The timing and process of weaning need to be individualized by mother and child. Weaning might be abrupt or gradual, take weeks or several months, be child-led or mother-led. Physicians need to guide and support mothers through the weaning process." I find the entire article a very useful read for any primary care provider who may find themselves in a position of counselling women on weaning. It certainly talks about the basics, and provides links to further sources of information. One particularly useful thing about this article is its section on recommendations for physicians, which includes the following suggestions:
For women who are returning to work, the articles suggests pumping as a method of promoting ongoing breastfeeding, as indicated: "Partial weaning is an option for the mother who wishes to continue breastfeeding. This can work well for the mother who is working or studying outside the home. Early morning, evening and night feedings can continue even if mother and baby are separated during the day. For times spent away from her baby, a mother can express milk. Pumping should allow her to maintain production of milk." Another useful resource, of the many, linked through by the RBR is the Breastfeeding Handbook published by the Baby-Friendly Newfoundland and Labrador Perinatal Program. Breastfeeding moms will often want to know how often they should be feeding their babies, including throughout the night. The Breastfeeding Handbook provides an answer for this: "All babies have their own feeding and sleeping habits. Breastfeed your baby as often as she is interested or 'on cue.' Many babies will need to breastfeed every 2–3 hours during the day and night, at least 8 or more feedings in 24 hours. Remember, breastfeeding at night boosts your milk production and prevents engorgement. Your baby may breastfeed more often at certain times of the day (every hour for 2–6 hours) and then sleep for a longer period. This is called cluster feeding and it is normal. Some mothers worry that they do not have enough milk if their baby seems to want to be on the breast often. Follow your baby’s cues. Frequent breastfeeding in the early weeks helps to establish a plentiful milk supply at six weeks. As your baby grows, she will set her own sleeping and feeding patterns. A breastfed baby may feed about every two hours during the day and sleep for longer stretches at night by the age of 2–3 months. There is no set age when a baby should sleep through the night. In fact, most healthy breastfed infants wake often for night feedings well into their first year of life." Like most of the counselling provided to parents with concerns, it usually involves reassurance, as most parents have many concerns despite the fact that most children develop normally. That being said, providing effective reassurance requires health care providers to know what clues suggest a potential problem. The key here is knowing what the problems look like, and then being reassured when evidence of those problems is not found. Even without answers to the multitude of creative questions parents may have, simply knowing what the reasons to worry about are, and reassuring if those worries are not present, is the key to providing effective counselling, with the understanding that the trajectory of childhood development is not homogenous and variability in and of itself is not problematic. One other issue to make mention of here is the fact that some women prefer not to breastfeed at all, for whatever reason. While breastfeeding is preferred by medical professionals in general, babies can receive sufficient nutrition using commercially available infant formulas. It is important for the sake of preserving the quality of the physician-patient relationship to be nonjudgmental when women choose to feed their infant using formula rather than breastmilk. There is an excellent guide put out by Alberta Health Services for medical professionals that gives an overview of the formula available and when different formulas may be recommended. You can reach it by the links through the Rourke Baby Record or here. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Fever Key Feature 1a: In febrile infants 0-3 months old: Recognize the risk of occult bacteremia. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Key Feature 1a: In febrile infants 0-3 months old: Investigate thoroughly (ex: blood cultures, urine, lumbar puncture +/- chest X-ray). Skill: Clinical Reasoning Phase: Investigation Key Feature 8: In an elderly patient, be aware that no good correlation exists between the presence or absence of fever and the presence or absence of serious pathology. Skill: Clinical Reasoning Phase: Hypothesis generation Newborn Key Feature 2a: In a newborn, where a concern has been raised by a caregiver (parent, nurse): Think about sepsis. Skill: Clinical Reasoning Phase: Hypothesis generation Key Feature 2b: In a newborn, where a concern has been raised by a caregiver (parent, nurse): Look for signs of sepsis, as the presentation can be subtle (i.e., not the same as in adults, non-specific, feeding difficulties, respiratory changes). Skill: Clinical Reasoning, Selectivity Phase: Physical, History Key Feature 2c: In a newborn, where a concern has been raised by a caregiver (parent, nurse): Make a provisional diagnosis of sepsis. Skill: Clinical Reasoning Phase: Diagnosis Urinary Tract Infection Key Feature 5: Given a non-specific history (ex: abdominal pain, fever, delirium) in elderly or very young patients, suspect the diagnosis and do an appropriate work-up. Skill: Clinical Reasoning Phase: Hypothesis generation, Investigation When I was in my third year of medical school I encountered a febrile infant in clinic who was just over a month old. My attending family physician recommended the parents bring their infant immediately to the Emergency Department, and because I was on a rural rotation, I had the privilege of heading over to the Emergency Department myself to follow the workup through. My preceptor urgently referred this infant to the Emergency Department because of the heightened risk of occult bacteremia in febrile infants under 3 months of age. According to the UpToDate article, Febrile infant (younger than 90 days of age): Definition of fever (2018), "Neonates and young infants may manifest fever as the only sign of significant underlying infection. The incidence of serious bacterial infection such as urinary tract infection, bacteremia, meningitis, and pneumonia is higher in infants younger than three months of age, particularly those under 28 days, than at any other time in childhood. In addition, these young patients can experience significant morbidity from some viral infections." A fever in a child less than 3 months old warrants an urgent workup in an Emergency Department as this can be the first sign of a potentially life-threatening infection/sepsis. The Emergency Department is the place in our healthcare system where this workup can be completed the most urgently and with the resources to do so as extensively as indicated. So what exactly does the workup of a febrile infant less than 3 months of age entail? Per the UpToDate article, Approach to the ill-appearing infant (younger than 90 days of age) (2018), and the BC Children's Hospital Febrile Infant Guideline, the investigations that are indicated in this situation include:
I also just want to make a little pitch here about fever in the other extreme of age. Like infants, elderly patients may be impaired in their ability to mount a significant immune response to an invasive infection, and may not even develop a temperature high enough to be considered febrile (typically around 38 degrees Celsius). It is important - when encountering a newborn or elderly patient who is unwell - to have a high index of suspicion for a source of infection, even if they aren't presenting with a fever. While the infant I encountered on this occasion had mounted a fever, other signs of sepsis to watch out for are included in the below table from UpToDate:  Furthermore, per UpToDate, "A clinical diagnosis of severe sepsis or septic shock is made in children who have signs of inadequate tissue perfusion, two or more criteria for the systemic inflammatory response syndrome (SIRS), and suspected or proven infection." See below for a table provided by UpToDate of the pediatric SIRS criteria:  By the end of postgraduate training, using a patient-centered approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Learning (Patients) Key Feature 1: As part of the ongoing care of children, ask parents about their children’s functioning in school to identify learning difficulties. Skill: Clinical Reasoning Phase: History Newborn Key Feature 6: In caring for a newborn ensure repeat evaluations for abnormalities that may become apparent over time (ex: hips, heart, hearing). Skill: Clinical Reasoning Phase: Follow-up, Physical Key Feature 7a: When discharging a newborn from hospital: Advise parent(s) of warning signs of serious or impending illness. Skill: Clinical Reasoning, Communication Phase: Treatment, Follow-up Key Feature 7b: When discharging a newborn from hospital: Develop a plan with them to access appropriate care should a concern arise. Skill: Clinical Reasoning, Patient Centered Phase: Follow-up Obesity Key Feature 7: As part of preventing childhood obesity, advise parents of healthy activity levels for their children. Skill: Clinical Reasoning Phase: Treatment Poisoning Key Feature 1: As part of well-child care, discuss preventing and treating poisoning with parents (ex: “child-proofing”, poison control number). Skill: Communication, Clinical Reasoning Phase: Treatment Well-baby Care Key Feature 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. Skill: Clinical Reasoning, Psychomotor, Skills/Procedure Skills Phase: Physical Key Feature 4: At each assessment, provide parents with anticipatory advice on pertinent issues (ex: feeding patterns, development, immunization, parenting tips, antipyretic dosing, safety issues). Skill: Clinical Reasoning Phase: Treatment Key Feature 5: Ask about family adjustment to the child (ex: sibling interaction, changing roles of both parents, involvement of extended family). Skill: Patient Centered Phase: History Key Feature 8: Even when children are growing and developing appropriately, evaluate their nutritional intake (ex: type, quality, and quantity of foods) to prevent future problems (ex: anemia, tooth decay), especially in at-risk populations (ex: the socioeconomicaly disadvantaged, those with voluntarily restricted diets, those with cultural variations). Skill: Clinical Reasoning Phase: History, Treatment A well baby is always a good thing! And having an easy and trustworthy method of knowing whether a baby is well is a double good thing. In medical school we were taught we needed to memorise the extensive list of childhood developmental milestones and remember just how many ounces of formula per kg of weight infants need. We were taught to always perform a comprehensive physical examination during a well child checkup, but one that included only the relevant manoeuvres, which tended to change as quickly as you went from one preceptor to the next. BUT THERE IS A BETTER, MORE EVIDENCE-INFORMED, MORE EFFICIENT, AND LESS STRESSFUL WAY. The Rourke Baby Record is an evidence-based pediatric flow sheet that assists physicians in assessing and documenting the routine well-child checkup. It is based on age and can be integrated into electronic medical records. It is my friend, and it's got my back with its guide to interpretation of what is considered within normal limits. The website has links to the WHO growth charts as well, if it wasn't already schmoozing me enough. Furthermore, it provides a template* for the entire encounter, prompting information gathering and anticipatory guidance as relevant to the child's age. With handouts for parents and a list of relevant resources for different-age related concerns (including for the initial discharge from hospital after delivery), along with evidence-informed recommendations for all of the anticipatory guidance you could dream of, no wonder these kids as displayed on their website are as happy as I am!  *Being a template for a generic encounter, it is important for the clinician to be astute in modifying the encounter as needed. For example, one of the prompts for information gathering in the first month of life is inquiry into siblings. I consider this to be a prompt to assess how others in the family in general, including but not limited to siblings, are adjusting to the new family member. This may include how parental roles are being affected, and who in the extended family is offering support. The RBR is a stimulus for a conversation, but should not be considered a literal and exhaustive encounter script. And, when it comes to physical exam maneuvers that aren't as enjoyable, like measuring head circumference or length, or assessing hip stability, I perform these opportunistically or else altogether at the end of the visit so that I disturb the child as little as possible. The template ensures you obtain the important clinical information, but I can choose how to acquire the most information and with more rather than less tact.
Once children are older than 5 years old, switch out your RBR for the Greig Health Record and you can continue on your merry way until a child has reached adulthood. |
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