Pediatric Primary Care Case Studies (21 page)

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Primary pediatric care
(4th ed., pp. 858–868). St. Louis: Mosby.

Kothare, S. V., & Kaleyias, J. K. (2008). The clinical and laboratory assessment of the sleepy child.
Seminars in Pediatric Neurology, 15
(2), 61–69.

Lubkin, I. M, & Larsen, P. D. (2005).
Chronic illness: Impact and interventions
. Boston: Jones and Bartlett.

Mindell, J. A., & Owens, J. A. (2003).
A clinical guide to pediatric sleep: Diagnosis and management of sleep problems
. Philadelphia: Lippincott, Williams & Wilkins.

Ozuah, P. O., & Sigler, A. T. (2001). Fatigue and weakness. In R. A. Hoekelman, H. M. Adam, N. M. Nelson, M. L. Weitzman, & M. H. Wilson (Eds.),
Primary pediatric care
(4th ed., pp. 1079–1084). St. Louis: Mosby.

Pelayo, R., & Dubik, M. (2008). Pediatric sleep pharmacology.
Seminars in Pediatric Neurology, 15
, 79–90.

Toitu, Y. (2001). Human aging and melatonin: Clinical relevance.
Experts in Gerontology, 36
, 1083–1100.

Tunnessen, W. W., & Roberts, K. B. (1999). Fatigue. In Tunnessen & Roberts (Eds.),
Signs and symptoms in pediatrics
(3rd ed., pp. 46–52). Philadelphia: Lippincott, Williams, & Wilkins.

Wagner, J., Wagner, M. L., & Hening, W. A. (1998). Beyond benzodiazepines: Alternative pharmacologic agents for the treatment of insomnia.
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, 680–691.

Ware, N. C., & Kleinman, A. (1992). Culture and somatic experience: The social course of illness in neurasthenia and chronic fatigue syndrome.
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White, P. D., Sullivan, T. P. F., & Buchwald, D. (2004). The nosology of sub-acute and chronic fatigue syndromes that follow infectious mononucleosis.
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UNIT II

Functional Health and Mental Health Problems

Chapter 6

The Well Infant

Anna Marie Hefner

A newborn baby, whether it is the first or last child, is unique and brings changes to family dynamics. The initial newborn visit provides a special opportunity for the healthcare provider to discuss the mother’s pregnancy and delivery, immediate postpartum mother and infant issues, and plans for individualized care of both the baby and family. For the discharge of a mother and her newborn occurring within 24 to 48 hours after childbirth, the American Academy of Pediatrics recommends that the first office visit occur as early as 2 days after discharge. Factors that determine the timing for scheduling this first visit include the healthcare needs of the newborn, the date of discharge of the mother and infant, and the concerns of the family.

According to the American Academy of Pediatrics (2004, p. 1435), the purpose of the initial visit is to:

•   Weigh the infant; assess the infant’s general health, hydration, and degree of jaundice; identify any new problems; review feeding pattern and technique, including observation of breastfeeding for adequacy of position, latch-on, and swallowing; and obtain historical evidence of adequate urination and defecation patterns for the infant

•   Assess quality of mother–infant interaction and details of infant behavior

•   Reinforce maternal or family education in infant care, particularly regarding infant feeding

•   Review the outstanding results of laboratory tests performed before discharge

•   Perform screening tests in accordance with state regulations and other tests that are clinically indicated, such as serum bilirubin

•   Verify the plan for health care maintenance, including a method for obtaining emergency services, preventive care and immunizations, periodic evaluations and physical examinations, and necessary screenings

Educational Objectives

1.   Apply the guidelines for management of newborn health care, including prenatal history and childbirth, assessment of infant’s general health, reviewing feeding patterns and technique, preventive care and immunizations, physical examination, and necessary screenings.

2.   Assess the quality of mother–infant interaction.

3.   Identify the strengths of the family and reinforce family education in infant care.

4.   Consider the cultural factors that might affect the healthcare plan and the family’s understanding and compliance with the plan of care.

   Case Presentation and Discussion

Lauren Calzada is a 4-day-old Mexican American female born to a 34-year-old gravida 2 para 2 Mexican American mother in a common law marriage. She has a previous male child, Anthony, born 3 years ago. She explains that her newborn daughter is breastfeeding every 2–4 hours and is healthy; however, the 3-year-old is whining all the time. She has noticed Lauren is more “yellow” than Anthony was at birth. Ms. Calzada is concerned about the jaundice Lauren is exhibiting.

What initial questions need to be asked of Ms. Calzada?

The healthcare provider should establish a baseline history that includes information about the following:

•   
Pregnancy:
Para and gravida status, when she first sought prenatal care, any maternal health problems (e.g., toxemia of pregnancy or gestational diabetes), any fetal health issues.

•   
Labor:
Length and complications.

•   
Delivery:
Type of delivery, use of instruments, any maternal or fetal complications.

•   
Hospitalization:
How soon after birth was the infant discharged home?

•   
Neonatal course or issues since discharge:
Feeding, voiding, sleeping, and any worrisome symptoms or signs or parental concerns.

Ms. Calzada says she remained healthy during her pregnancy. Her labor was unremarkable, with a spontaneous vaginal delivery 6 hours after the first contractions, just 2 days before her due date. Ms. Calzada had a small labial laceration requiring sutures with no further complications. Lauren had a “small lump on the left side of her head” (cephalohematoma) at delivery, but no other problems were noted after delivery or during the hospital stay. Ms. Calzada breastfed Lauren in the delivery room and experienced no breastfeeding problems. She and Lauren were released from the hospital 36 hours after delivery, and since then Lauren has been breastfeeding every 2–3 hours and voiding adequately.

Last evening she noticed Lauren had “yellow cheeks,” and by morning the jaundice appeared on the baby’s chest. She called the healthcare provider and made a late morning appointment.

What additional questions will you ask Ms. Calzada related to the jaundice?

Before answering this question, here is essential information about jaundice in the newborn that you need to consider.

Pathophysiology of Newborn Jaundice

Jaundice results from the deposition of unconjugated bilirubin in the skin and mucous membranes. It is a result of the shortened life span of the red blood cells, declining hematocrit, immature liver uptake and conjugation of bilirubin, and increased reabsorption of bilirubin in the intestines. The common risk factors include ABO incompatibility, prematurity, breastmilk jaundice, and a previously affected sibling.

Additionally, cephalohematomas, bruising, and trauma from an instrumented delivery may increase the risk for elevation of serum bilirubin.
Ms. Calzada told you about Lauren’s “bump” and the hospital record noted a cephalohematoma on the left temporal area.
In a cephalohematoma, there is a collection of blood under the periosteum. This blood breaks down into heme, which becomes bili and may contribute to jaundice, and iron, which is recycled into new red blood cells. However, jaundice is present to some degree in most newborns and is known as physiological jaundice (De Almeida & Draque, 2007).

Jaundice can be detected when blanching of the skin reveals a yellow color. It starts on the face and progresses caudally. The higher the total bilirubin, the further it progresses down the body (Johnson, Bhutani, & Brown, 2002). Jaundice is difficult to detect in dark-skinned newborns. The examination should always occur in a well-lit room.

Other information you should obtain includes the following:

•   What is the mother’s blood type and baby’s blood type?

•   What is the Rh factor of the mother?

•   Has the baby had a fever?

•   Has the baby or the mother been exposed to any person or persons with an infection in the 2 weeks prior to delivery?

•   What have the baby’s feeding and voiding patterns been since discharge from the hospital?

•   What was the mother’s first pregnancy experience like and was she able to successfully breastfeed her first child?

Your further questioning reveals the following additional information:

According to Ms. Calzada, Lauren breastfeeds every 3–4 hours, 5 minutes on each breast. She has approximately four to five wet diapers a day; the urine is dark yellow in color. Ms. Calzada reports that Lauren has had one green stool since discharge. There were no exposures to individuals with infectious diseases in the 2 weeks prior to her delivery or since then. Her first pregnancy resulted in a healthy, term male infant without complications. She was successful in breastfeeding Anthony for his first year of life.

You review the results of the laboratory studies conducted during their hospital stay.

The laboratory reports note that Ms. Calzada’s blood type is O+, Lauren is A+, direct Coombs negative. Lauren’s total bilirubin at 12 hours was 1.8 mg/dL.

The healthcare provider should also discuss Lauren’s sleeping schedule. Ms. Calzada tells you that Lauren is sleeping longer stretches of time, almost 4 hours at times, allowing her to get the housework done.