Pediatric Primary Care Case Studies (132 page)

Obtaining a complete prenatal and birth history will be a key factor in evaluating subsequent health risk factors for this infant. Starting with the hospital stay, it will be important to find out as much as possible about Bobby’s course of hospitalization. You begin with the pregnancy and ask about whether there were any complications other than the prematurity. After birth, was the infant in the neonatal intensive care unit (NICU) or did he remain with the mother or in the newborn nursery? Was he treated with antibiotics and, if so, does she remember their names? Did he have hyperbilirubinemia and/or did he receive treatment; if so, what? Did he have any breathing problems during the hospitalization? What was he fed, how much, and how often, and what was his birth weight?

According to the mother, she and José weren’t planning on having Bobby but “things just got out of hand.” Bobby was conceived the first time they had sex. She started prenatal care at 5 months gestation and had problems with her blood pressure “going real high” and her feet and hands swelling. She had to see the obstetrician frequently because of her blood pressure and needed to take blood pressure medication, which she is still taking. She went into labor early and delivered Bobby vaginally after a 6-hour labor. He cried right away, and the doctor said he was small but that was expected since he was early. She and the infant stayed in the hospital for 4 days without complications. She can’t remember how much he weighed when he went home but “the nurse said he lost a little weight from birth, but that was expected.” Bobby is now 6 days old, and this is his first visit to you for follow-up care.

What has been Bobby’s course since being discharged home with Mom?

The following discussion will help you review common problems seen in the late preterm infant and to determine whether this infant has experienced any of these problems or associated sequelae.

You explain to Sandra that you will check Bobby’s weight today and compare it to her discharge papers that she has brought with her. You ask her if she is breastfeeding or bottle feeding, and if bottle feeding, what type of formula she is using; how much does the baby take (or if breastfeeding, how many minutes at the breast and inquire if she switches sides); how often is the infant feeding; how many wet diapers per day and frequency of stooling; how long
does the baby sleep; and does the infant have any trouble with breathing, feeding, rashes, or any other concerns she has.

Sandra states that she is trying to breastfeed Bobby, but she isn’t very good at it. She states that the nurses told her to feed him every 2–3 hours. She is trying her best but is frustrated that she doesn’t seem to have very much milk. She tells you that the baby gets cranky when she tries to put him to breast and that she is so tired now. She tries to switch to both breasts but feels awkward. She says that the nurses told her not to give him anything else but breastmilk, so she hasn’t given him a bottle. They did show her how to pump while in the hospital, but she doesn’t have a pump at home. Sandra tells you that he seems to have quite a bit of poop, almost every diaper change, so she guesses that there is urine in the diaper as well. She says that Bobby doesn’t seem to have any other issues in general, but that he does seem to sleep all the time and she has to wake him up to feed, and then he starts crying because, according to Sandra, he isn’t getting very much milk. She is frustrated because she has been told that breastfeeding is best, but José’s mother keeps telling her to give the baby a bottle. Before moving on to further discussion, you take this moment to encourage her with the breastfeeding and inform her that you will arrange for a lactation consultant to come to her home to assist her and arrange for her to get a breast pump.

Social and Emotional History

As you begin to obtain a complete history from Sandra regarding her baby, you ask her about home life: her biologic parents, current living arrangements, and future plans for education or a career (both Sandra and José). How are they supporting themselves and the baby (food, shelter, clothing, medical insurance)? What were the issues surrounding the conception and the use of birth control? The possibility of postpartum depression (maternal and paternal) should be assessed using a brief assessment tool such as the Beck Depression Scale (Mancini, Carlson, & Albers, 2007; Whooley, Avins, Miranda, & Browner, 1997).

She reveals that she got pregnant by her Hispanic boyfriend, José, also 17 years of age, and, as a result, Sandra’s mother “disowned” her. She is now living with her boyfriend and his family, a large Mexican family. José’s mother, father, and four younger siblings are all living in a small three-bedroom house. She and José have no space to themselves. José’s parents speak minimal English. Sandra says she feels stressed because she cannot easily communicate with them and has to rely on her boyfriend to translate for her. José’s mother tries to help with the baby and has been very helpful with changing diapers and rocking the baby when he cries. She says that she has been happy overall about the pregnancy, although she had no idea about how difficult it was to be a new mom, but that she plans on finishing school because José’s mother can help with the baby. She and José have talked about marriage, but are waiting for now. She says she is on WIC and does have Medicaid for insurance.

You use the two-question depression screen that the U.S. Preventive Services Task Force (Gaynes et al., 2005) recommends as a quick screen for adults. The two-question screen is as effective as longer screening tools. The two simple questions to ask are:
During the past month have you been bothered by 1) feeling down, blue, depressed, or hopeless? and 2) feelings of little interest or pleasure in doing things? Sandra answers no to both, and you decide that at this point in time she does not have postpartum depression.

Cultural and Teenage Dynamics

Cultural/socioeconomic factors must always be considered when evaluating patients. The healthcare provider working with ethnically diverse patients must reach out to patients and learn about their cultures, beliefs, and values as well as addressing the dynamics of teenage parenting. Sociodemographic risk factors of teenage pregnancy include poverty, low education level, inadequate prenatal care, and unmarried status (Chen et al., 2007). Thus, one of the most important issues to address in teenage parents is their lack of support as well as the lack of access to resources. Some perceptions of teenage parents include that they lack emotional and mental maturity, lack the ability to provide financial stability due to education interruption or to qualify for particular jobs due to their age, lack preparation for motherhood or fatherhood, and a general feeling that teenagers are unsuitable to be parents because they are still children themselves. This often leads to social abandonment when they become parents and worsens the already turbulent adolescent period (Hanna, 2001).

Cultural diversity can also add to difficulties in teenage parenting. In this particular discussion, the father of the baby is Hispanic, and typically Hispanic households are male-dominated and take great pride in their sons. There may be alternative healthcare practices that affect the care of a newborn and influence when to access traditional medical care. During this past decade great emphasis has been placed on developing family-centered care management strategies. This translates to all aspects of health care, including private physician offices and community clinics. Thus, it is critical to include the family in all decisions regarding care as well as recognizing cultural differences that may affect the delivery of care at home. Explanations should be sensitive to cultural issues and potential barriers to effective communication. Language translators or cultural brokers (individuals who are fluent in the language and sensitive to customs and nuances) may be very helpful. Careful wording of health and social questions is essential as well as explaining the content of the questions and why the healthcare provider needs such information. Identifying cultural beliefs and integrating appropriate management plans is important to the success of the treatment and management plan for the infant and his or her mother. In this case, there may be cultural differences operating between the mother and her Hispanic surrogate family as well as between the mother and the healthcare provider.

What information will be especially important to obtain on this newborn examination?

Physical Examination

On physical examination, you find a sleeping male infant who appears comfortable with regular respirations. Vital signs for this age are within normal limits, and auscultation of lungs and heart sounds are also normal. The infant’s weight at birth was 5 lbs 5 oz. Current weight is 4 lbs 12 oz (approximately 11% weight loss). This places the infant at approximately the 10th percentile on a premature growth chart for boys, but the current weight loss is the more concerning issue. You notice milia on the infant’s nose, and the anterior fontanel is open, of normal size, and flat but not depressed. His skin is slightly jaundiced in color and the mucous membranes are wet. The infant’s abdomen is soft and flat with active bowel sounds; the umbilical cord is drying without redness or other abnormalities. The infant’s genitalia is Tanner stage 1 with both testicles descended, the penis uncircumcised, and the anus patent. Tone appears to be within normal limits; however, the infant is slightly difficult to awaken but when he does awaken he has a robust cry and is easily soothed.

Making the Diagnosis

The differential diagnoses for assessing a late-preterm infant include carefully evaluating for each of the previously discussed problems that can occur in this population. In this particular case study, the infant’s jaundiced skin, slight lethargy, and the poor feeding are red flags that require further evaluation. The healthcare provider should evaluate Bobby for three key potential problems:

1.
Hyperbilirubinemia:
Total and direct bilirbubin levels and the feeding history should provide you with information to distinguish between conjugated versus unconjugated hyperbilirubinemia.

2.
Sepsis:
A complete blood count (CBC) with differential should serve for sepsis screening. Some practitioners may obtain a blood culture at the same time, but usually a CBC is sufficient initially. Infection is also a differential diagnosis for hyperbilirubinemia (Moerschel et al., 2008). The CBC should be similar to a term, healthy infant, which often has an elevated white blood cell (WBC) count for the first 2 weeks of life (up to 30,000 leukocytes), and then decreases to normal adult levels. Of concern would be a low WBC count, a persistently elevated WBC level, or an elevation in the segmental band count on the differential (Polin & Spitzer, 2001).

3.
Dehydration:
Comparison of the infant’s current weight compared to birth weight, feeding history including volume and frequency of feedings, as well as the number of wet diapers will help with this assessment. Do a 24-hour recall of feedings, number of wet diapers, and stooling pattern. Normal weight loss for newborns is 5–10% of birth weight for the first week of life. Watch the mother breastfeed her infant to assess proper latch on and sucking by the infant; encourage 10–15 minutes of breastfeeding
on both sides. Approximate the amount of breastmilk the infant is receiving by comparing to how much she pumps in 10–15 minutes. And, of course, make appropriate referrals to lactation consultants as needed.

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