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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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2nd
Quarter Review: January 2002
Breastfeeding: First week: advantages and disadvantages of
breastfeeding.
- Advantages: protection from infection: diarrhea, otitis, respiratory
such as bronchiolitis, meningitis, sepsis; protection from allergy, SIDS,
NEC; higher IQ (more protein particularly for preterm); protection for
mother: breast/ovarian cancer.
- Problems: local tenderness, engorgement, mastitis, jaundice,
hypernatremic dehydration, FTT, caries, rickets.
- Contraindications: HIV, galactosemia, tb, psychosis, neurosis,
syphilis, malaria; medications: limited – reference Sept 2001 pg 776;
drugs oabuse, cytotoxic drugs; give with caution: lithium, Phenobarb,
primidone, antidepressants, antipsychotics.
- Discussed meds and reference in September Peds 2001 describing which
few medications are contraindicated in breastfeeding (cytotoxic drugs,
drugs of abuse, a few to be concerned about).
Breastfeeding: Second week: Frequently asked questions:
- 3 phases of bf (colostrums: 0-5 days; transitional: 5-15 days; mature
> 15 days. Discussed foremilk and hindmilk of mature milk – latter: more
calories, protein.
- Frequency of nursing: 10-15 minutes/side; how often: 2-2 ˝ hours
between nursing; do not supplement until 3 weeks of age; how to combine
formula and breastfeeding; how to wean.
- Role of pediatrician in promoting breastfeeding (AAP policy statement
1997)
The Confusing World of Vitamins:
- 54% of children in the US take supplemental vitamins.
- Therapeutic effectiveness of Vits A, B1, B6, B12, C, D, E, K and
Folate reviewed.
- Focus of Vitamin E in its role as an antioxidant for heart-healthy
behavior and Folate in its role in reducing level of homocysteine
(elevated in premature heart disease, stroke); this now being questioned.
- Internet addresses – merging with herbs, other “naturally” occurring
products.
- What do we need to tell parents? Routine supplementation is not
indicated except in dark-skinned breastfed babies not getting much
sunlight
Varicella Vaccine:
- Now required in state of Georgia for school, so will increase; however
in 1999: only 59% had received this vaccine.
- Effectiveness: 100% of serious infections prevented (such as
necrotizing fasciitis), but total effectiveness: 80% - ie 20% get mild
infection despite vaccine.
- Give vaccine within 72 hours of exposure to varicella: effective
prophylaxis.
- Side effects: cutaneous varicella in 4-5% about 5-26 days after shot –
mean number of lesions = 5 versus natural infection: 250-500 lesions. Can
also get modified Varicella – about 10-100 lesions.
- Contraindications: pregnancy, immunosuppression, salicylate use,
steroids (2 mg/kg of prednisone) over 14 days in a row; after VZIG or IVIG
or blood products.
Sleep: discussion of average numbers of hours baby sleep,
when they take naps and how that changes with age: 2 naps 2 hrs each
3mos-12mos; 1-2 naps totaling 2 hours 12-18 months; 1 nap for 1 hour between
2 and 3 years of age.
- Sleep disturbances discussed: risk factors include
co-sleeping, parental over-responsiveness; social stresses, medical
disorders such as colic.
- Treatment of sleep disorders: 4 age groups (under 2
months of age – most babies don’t sleep so no interventions usually needed
for them):
- 2 mos – 6 mos: feed 10PM and 6 AM not 7-8 PM; have child out of
bedroom by 2 months of age.
- 6 mos – 2 years: Ferber program. Keys:
- put down awake only
- follow time interval instructions in chart
- never pick up, change diapers, etc; 2-3 minutes/visit only
- 2 – 5 years: control issues. Use behavior modification techniques;
may need to give meds to get sleepy for 4-5 days, or even eventually
latch the door.
- Over 5 years of age: nightmares, night terrors, phobias, school
problems.
Pneumococcal Vaccine:
- Review of Prevnar recommendations: under age 2; over age 2: different
program depending on when start the series.
- Anticipated effects: dec otitis media, pneumonia, bacteremia,
meningitis
- Role of Polysaccharide Vaccine (23 serotypes): over age 2: high risk –
2 shots
Teething:
- Produces only irritability, drooling, facial rashes – no evidence that
is associated with diarrhea or fever.
- Use only Tylenol or Ibuprofen; teething rings OK but don’t refrigerate
first (cold panniculitis can result). Sugar on pacifier may help, but the
following also get used: chamomilla tea, viscous lidocaine, teething
powders, paregoric, orajel, whiskey on pacifier, Phenobarbital.
Tooth Eruption:
- Rule of 4’s: 4 teeth by 1 year then 4 teeth per 4 months after that up
to 28 months.
- Avulsed deciduous tooth: no treatment needed; avulsed permanent tooth:
transport in milk, water, saline – do not scrub the tooth; bruised tooth –
look for abscess development: gumboil.
- Eruption blisters are normal and need no treatment; mucoceles on lips
usually no treatment needed.
- Don’t suture lacerated tongue unless through and through injury;
- Pediatrician should refer children with lacerations that cross the
vermilion border.
Car Seats: Child faces back in back seat until 20 pounds
and 1 year of age; booster seat at age 4 years; seat belt until age 7-8;
back seat until age 12. Learn how to install them!
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