Pediatric Primary Care Case Studies (22 page)

Social History

Lauren’s father is deployed in Iraq and will be on leave in 4 months. Ms. Calzada’s mother is expected to arrive in 1 week and will stay with her daughter for 1 month. They live in two-bedroom military base housing, and Ms. Calzada has a few friends who come by when they can. Her church provides her meals since she has been home each evening. She says, “I’m coping OK. My church friends are a big help but I’ll be happy to have my mother come and help me.”

Physical Examination

The vital signs are T 37° Celsius, pulse 142, respiratory rate (RR) 48, weight 3.2 kg (45th percentile), length 50 cm (75th percentile), and head circumference 34 cm (75th percentile). The infant is jaundiced to the abdomen. The anterior fontanel is flat and slightly sunken; oral mucosa is moist. No cephalohematoma or bruising is present. The sclera of both eyes are clear. Muscle tone and activity are normal. Reflexes: suck and swallow strong and coordinated, rooting intact. The remainder of the physical exam is normal.

Making the Diagnosis

Differential Diagnosis

The differential diagnoses for jaundice in the newborn include ABO incompatibility, infection, physiological jaundice of the newborn, and breastmilk jaundice.

This history and physical examination are consistent with a diagnosis of physiological jaundice and may be exaggerated with breastfeeding jaundice. She has jaundice to the abdomen, breastfeeding every 3–4 hours, and a history of a cephalohematoma.

Other problems that need to be addressed include:

•   Breastfeeding techniques

•   Military family with husband deployed

How do you plan to treat the jaundice?

Do you need to do anything to confirm the diagnosis, such as laboratory studies?

At this time, a total and direct bilirubin would need to be done. The laboratory results for Lauren are total bilirubin of 6.8 mg/dL with a direct bilirubin
of 0.1 mg/dL. Additional testing would need to be done if there were additional symptoms such as a fever, listlessness, increased irritability, or poor feeding. A complete blood count, reticulocyte count, and serum albumin levels may also need to be checked.

Therapeutic plan: What will you do therapeutically?

Treatment is not usually necessary with physiological jaundice. However, Lauren would need to be kept hydrated. Mother can increase the frequency of breastfeeding to every 2–3 hours during the waking hours and allow baby to sleep up to 4 hours at night. Physiological jaundice usually resolves within 1 to 2 weeks.

Educational plan: What will you do to educate Ms. Calzada about breastfeeding and its management?

Jaundice

Ms. Calzada needs to bring Lauren back to the healthcare provider if the baby develops a fever, becomes listless, or is not feeding well. Jaundice is usually not dangerous in the term healthy newborn. Additionally, Ms. Calzada should call the provider if the jaundice becomes more severe, lasts longer than 2 weeks, or if other symptoms develop.

Nutrition: Breastfeeding

Breastfeeding should be for a minimum of 10 minutes on each breast or until the baby is content. Watch Ms. Calzada breastfeed her infant. Review how to hold the baby and correct latching on, if you note problems with her technique. Discuss that newborn infants typically demand feedings 8 to 12 times per day for the first 4 to 6 weeks of life. Lauren can also receive sunlight through adequate exposure to indirect sunlight. Lauren’s mom can place the baby by a window that has sun exposure, but not in such a position that the sun is directly shining on the infant. Mom can also take the baby outside with her to sit in the shade on a warm day. Discussion of bowel movements—frequency and transitional stools, voiding patterns of six to eight wet diapers per day—should also be addressed.

What other areas of education and anticipatory guidance are needed for the family?

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents
(Hagan, Shaw, & Duncan, 2008) identifies three key areas of anticipatory guidance that should be addressed at each well child visit. Because this sick visit is focusing on the assessment and management of Lauren’s jaundice, you will not want to overwhelm the mother with extensive healthcare teaching. The healthcare provider should mainly use this time to address the issue of jaundice brought forth by the mother. However, the healthcare provider should also discuss at least one to two anticipatory guidance issues (e.g., car seat use and limited outings) at this visit and explain to Ms. Calzada that they will be discussing anticipatory guidance
issues at future wellness visits. The clinician will need to identify what anticipatory guidance topic or topics should be a priority issue addressed at this time. The focus could be a safety, sleep, or general infant care issue that emerged from information obtained during the history and examination of the infant. Keep in mind that a discussion about safety, such as the use of an infant car seat, is always an appropriate issue to address at every healthcare encounter.

Subsequent visits will address the following areas of anticipatory guidance:

•   Promotion of healthy and safe habits

   
Car seat safety:
Position the newborn in the back seat of a car, facing backwards, following manufacturer’s instructions and the vehicle’s owner manual. The infant needs to remain in the car seat at all times during travel.

   
Crib safety:
Slats in the crib should be no further than 2⅜ inches apart.

   
Smoke-free environment:
Families should make their home and car nonsmoking zones.

   
Home safety:
The baby should never be left alone in water or on high places such as changing tables, beds, chairs, or sofas. Keep one hand on the baby.