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Continuity Clinic Notebook:
Preface and Introduction:
Reviews of Each Talk Given in the First 3 Quarters of 2001-2002
After-Hours Phone Calls - What Do You Do?
Chapter I. The
Prenatal and Well Child Visit:
The Prenatal Visit, Nursery and Well-Child Examination Issues
Chapter II. The Evaluation
of the Sick Children
Chapter III. Adolescent Issues
Chapter IV. Ethics, Dealing with Death
Chapter V. Other Aspects of Private
Practice, Business, Managed Care
Appendix: Well-Child Forms
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1st Quarter Review – October
2001
Telephone Triage: Do not hesitate to bring children in to
the clinic the next day.
- Telephone calls should take no more than 3-5 minutes and should
specify: ER now, appointment the next day, advice only.
- Your job is not to answer all the parents’ questions, but to determine
the proper disposition of the call.
Body Language and the Office Visit: Remember to always
- Close the door, sit down and give eye contact with the family.
- Say something personal about each baby. Do complete physicals on
children even if their chief complaint is an earache.
- Go back in the room with the attending.
- When attending leaves, summarize (briefly) the plan.
Immunizations: Must keep up with all the changes that have
occurred:
- Dtap: must have 6 months between 3rd and 4th shots
- Prevnar: if not started, then don’t give over age of 2 unless high
risk
- IPV # 3 can be given between 6 and 18 months. We give at 6 months.
- Hemoglobin/lead: we are changing to 12-15 months of age.
- FEP: with hemoglobin and lead: coming soon.
- Comvax: suggest that we give full 4 HIBs despite their ad.
- Must give MMR and Varicella after the 1st birthdays – not before.
Metabolic Screen: discussion of the 8 conditions for which
Georgia screens:
- Sickle cell, thyroid disease (TSH is key – if in doubt “highly
sensitive TSH”), PKU, Tyrosinemia, Galactosemia, CAH (elevated 17-OH
progesterone), Maple Syrup Urine Disease (high leucine), Homocystinuria
(high methionine).
- Discussion of others done in other states.
Colic: Definition: Rule of 3’s: 3 hours a day, 3 days a
week, 3 weeks to 3 months.
- Differential Dx: must always remember to consider esophagitis when
dealing with babies with colic.
- Many unproven remedies (Chamomille tea, gripe water, health food
store, even chiropractic treatment). Can be associated with intolerance
to or allergy to milk protein.
- If mother is breastfeeding, many babies will improve by:
- limiting milk and all milk products in the mother for 10 days;
usually dramatic if child improves. If no improvement, then have mother
go back to taking milk protein; if improved, must progress slowly with
milk
- products first, then with milk later.
- Formula fed: if switch consider predigested formulas including Whey
(Carnation); Meds such as Levsin and Donnatal: can be useful.
Bottles, Nipples, Feeding:
- Nipples: stage 1,2,3: depending on size of nipple hole; shape varies
- Bottles : review of Avent (up to 4 holes); Dr. Brown’s natural flow
feeding system; Adiri (looks like a human breast);
- Others: the Pacifeeder, Waterford crystal for your shelves at home
- Bottle Bundle (U shaped pillow with elastic bottle holder), and Bottle
Bunny: you hold the baby, not the bottle: 4 different positions
- Cleft palate: Haberman feeder, Meade Johnson: nipple firm on one side,
soft on the other
Diapers and Diaper Rash
Review of different kinds of diapers from the least to the most
expensive (Rash guard Pampers). When treating diaper rash, ask about the
type of diapers used.
- Rash: remember atopic derm common in resistant rashes.
- Most: contact and require only barrier creams:
- Desitin, A and D, Balmex, etc: most have zinc oxide, cod liver oil,
petrolatum, lanolin.
- Balmex and Flanders contain Peruvian balsam.
- Less common causes: candida, psoriasis, acrodermatitis, histiocytosis,
tinea, seborrhea. We overtreat for candida.
Influenza: diagnosis and prevention.
- Discussion of symptoms, incubation period (1-3 days), laboratory
testing, treatment (over 1 year of age with Rimantadine and Amantadine),
Relenza over 5 years; Tamiflu: over 12 years of age.
- Prevention: nasal vaccine not approved this year.
- Limited supply of the influenza vaccine so encourage its use primarily
in those with higher risk: Over 9 yrs: 1 shot of 0.5cc; 3-9 yrs: 2 shots
one month apart of 0.5cc; 6mos to 3 years: 2 shots a month apart of
0.25cc.
RSV: Synagis (15 mg/kg per month): indications include:
- Infants and children under 2 years of age with chronic lung disease
who have required medical therapy within 6 months before RSV season.
- Prematurity
- 24-28
weeks: prophylax up to 1 year of age
- 29-32
weeks: prophylax up to 6 months of age
- 33-35
weeks: up to 6 months of age based on risk factors
Contraindications: children with cyanotic heart disease, though OK to give
to those with acyanotic heart disease.
Anemias: Discussed were the various types of red cell
problems including: iron deficiency, lead poisoning, hemoglobin C, hemolytic
disease, macrocytic anemias, Fanconi’s, transient erythroblastopenia (TEC),
G6PD def., beta thal trait.
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