2019-20 TOW #1: Infant Well Child Care

It’s exciting to kick off another year of continuity clinic teaching and our TOW series.

We are starting with a review of well child care at different ages in the first 4 weeks. This is a great opportunity to highlight recommended screening and priorities for these visits, and your clinical pearls. For interns not in clinic this month, please refer back to them later!!

Materials for this week:

Key take-home points:

  1. How do we prioritize what to cover in infant well child checks? There is widespread acknowledgement that providing comprehensive WCC is difficult in a typical ~20 minute visit, and it’s impossible to cover everything. National organizations like the AAP and pediatric research have helped define key priorities. And, others, including one of our own faculty, Tumaini Coker MD MPH, have highlighted the need to do more to address social determinants of health in WCC. One critical element in providing patient-centered care is to first ask about the parents’ concerns and priorities, e.g., “What do you want to make sure we talk about today? What are your questions and concerns?”
  2. How can Bright Futures resources be used? Bright Futures is the AAP-endorsed and supported guidance for primary care practices to prioritize components to include in comprehensive well-child and adolescent care. For each recommended well child check from newborn to age 21, there are guidelines for screening and 5 key recommended areas to discuss. For infants, the major 5 areas to prioritize are family functioning, development, growth and nutrition, oral health, and safety. Many sites use Bright Futures patient education handouts, which are great to review briefly when preparing for visits.
  3. What are the most important evidence-based components of infant visits? Providing immunizations and helping families stay up to date (more on this in a future topic!) is the most evidence-based. There is also evidence for programs that help parents thrive in parenting roles. We want to identify untreated mental illness or substance abuse, and if parents understand normal infant behavior, such as crying, and how to connect with and comfort their infants. Strategies like those taught in Promoting First Relationships (PFR) are effective (more on that to come as well). Questions to help explore include: “How are you doing? How are things going for your family?” To explore the relationship, perception of infant, we can ask “Tell me about your baby. What do you like best about him/her?” or “What has been difficult? What has surprised you?” These help us identify red flags for high-risk social interactions that may warrant more support.
  4. What are the recommended screenings for infant visits? It varies by age, but after the newborn hearing and metabolic screenings, most screenings (including blood pressure, vision, hearing, and anemia screenings) are selective for at-risk infants, such as for preterm infants or those who have abnormal findings on exam or by parent report. It is recommended to do a formal development screening at 9 months. In addition, we can make the case for the benefit of routine screening for social determinants of health (poverty, education, legal issues, housing and food security-more on these to come).
  5. What ways can we build rapport with parents for infant visits? Acknowledge how hard parents are working, and normalize how difficult it can be caring for infants. Also notice their strengths as a parent. It’s helpful to note out loud the positives about their interactions with their babies, e.g., “Wow, look at how your baby gazes at you – it’s so clear how much they want to see and hear you. It’s amazing how she already knows you. When you respond with comforting like that, this helps her feel safe and secure and know she’s loved.”

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