Infancy Visits Prenatal Through 11 Months BFG 4TH ED.indb 303 1/20/17 2:47 PM Infancy Prenatal Visit VISIT PRENATAL INFANCY Context A Prenatal Visit is recommended for all expectant communication for questions, the procedure for families as an important first step in establishing scheduling appointments, and after­hours care. a child’s medical home. Some parents use this During the Prenatal Visit, the health care pro­ opportunity to select a health care professional, fessional can review the importance of a healthy and this first visit is about establishing a relation­ maternal diet for fetal development as well as ship. It provides an opportunity to introduce identify any unique dietary concerns for the fam­ parents to the practice, gather basic information, ily, including any food allergies or intolerances, provide guidance, identify high­risk situations, cultural feeding practices, and the use of herbal 1 and promote parenting skills. The Prenatal Visit or complementary products. The Prenatal Visit is especially valuable for first­time parents; sin­ also presents an opportunity to inquire about, gle parents; families with high­risk pregnancies, and document, important aspects of pregnancy pregnancy complications, or multiple pregnancies; history, including potential exposures to toxins parents who anticipate health problems for the (eg, lead, alcohol, drugs) as well as to reiterate newborn; parents who have experienced a peri­ messages about healthy behaviors. Breastfeeding natal or infant death; and parents who are plan­ promotion is a key aspect of this visit, in particular ning to adopt a child. Health evaluation for newly for expectant mothers who have not yet decided adopted children has been reviewed, with recom­ on a feeding method or who are unsure about the 2 mendations provided. benefits or their ability to successfully breastfeed. Optimally, the Prenatal Visit entails a full office The benefits of breastfeeding for the mother and visit during which the expectant parents have the baby can be emphasized and parental questions opportunity to meet with the health care profes­ or concerns about breastfeeding and human milk sional. Among issues for discussion are the impor­ can be addressed. tance of early skin­to­skin contact and routine The health care professional also can inquire about newborn screening, including blood, bilirubin, the family constellation; the family’s genetic his­ hearing, and critical congenital heart disease tests. tory and health beliefs; the mother’s health and Other issues for discussion are the anticipated wellness, including her mental health, life stress­ timing of the newborn’s discharge from the nurs­ ors, status of health insurance coverage for the ery, common health care concerns for a newborn mother and other family members, and support during the first week of life, and normal early new­ systems; and the couple’s developmental adaptation born behaviors. This visit also provides an oppor­ to becoming parents. The family’s preparations tunity to provide an overview of health supervision for the newborn’s birth and homecoming can be during the first year and to discuss the practice’s assessed during this discussion, as can potential routines for handling telephone or electronic safety concerns and resource needs. This will help 305 BFG 4TH ED.indb 305 1/20/17 2:47 PM Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents the health care professional determine the avail­ Before a baby’s birth, many parents do not have the ability of support for the family at home and within opportunity to meet their baby’s health care profes­ the community. sional during a full prenatal office visit. However, The health care professional should reach out to a practice may use alternative strategies to obtain the prospective parents, emphasizing the impor­ information once the parents have decided to use tance of each parent’s role in the health, develop­ the practice for their primary care and medical INFANCY ment, and nurturing of the child, and encouraging home. These strategies can include group prenatal PRENATAL VISIT PRENATAL the parents and other important caregivers to visits, a prenatal/family history completed by the attend subsequent health supervision visits, parents, or telephone contact. if possible. Priorities for the Prenatal Visit The first priority is to attend to the concerns of the parents. In addition, the Bright Futures Infancy Expert Panel has given priority to the following topics for discussion in this visit: XX Social determinants of healtha (risks [living situation and food security, environmental risks, pregnancy adjustment, intimate partner violence, maternal drug and alcohol use, maternal tobacco use], strengths and protective factors [becoming well informed, family constellation and cultural traditions]) XX Parent and family health and well-being (mental health [perinatal or chronic depression], diet and physical activity, prenatal care, complementary and alternative medicine) XX Newborn care (introduction to the practice as a medical home, circumcision, newborn health risks [handwashing, outings]) XX Nutrition and feeding (breastfeeding guidance, prescription or nonprescription medications or drugs, family support of breastfeeding, formula-feeding guidance, financial resources for infant feeding) XX Safety (car safety seats, heatstroke prevention, safe sleep, pets, firearm safety, safe home environment) a Social determinants of health is a new priority in the fourth edition of the Bright Futures Guidelines. For more information, see the Promoting Lifelong Health for Families and Communities theme. 306 BFG 4TH ED.indb 306 1/20/17 2:47 PM Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents Health Supervision TheBright Futures Tool and Resource Kit contains Previsit Questionnaires to assist the health care profes­ PRENATAL VISIT PRENATAL sional in taking a history, conducting developmental surveillance, and performing medical screening. INFANCY History The prenatal history may be obtained according to the concerns of the family and the health care professional’s preference or style of practice. General Questions ■X How has your pregnancy gone so far? What are similarities and differences from what you expected? From previous pregnancies? Have you had any prenatal testing done? ■X What questions do you or other family members have about your baby after you deliver? Are there any concerns about the health of your baby? ■X What have you heard about the purpose of routine child health care? What have you heard about immunizations? ■X What do you think might be the most delightful aspect of being a parent? What do you think might be the most challenging aspect of being a parent? ■X Where do you get information when you have questions about health issues or caring for your baby? How do you prefer to receive information? Family History ■X Obtain a comprehensive family health history. A family history questionnaire can be found in the Bright Futures Tool and Resource Kit. Social History ■X See the Social Determinants of Health priority in Anticipatory Guidance for social history questions. 307 BFG 4TH ED.indb 307 1/20/17 2:47 PM Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents Surveillance of Development What have you heard about what newborns can do at birth? ■X Newborns are able to smell (especially their mother’s breast milk), hear their parents’ voices, see up to a distance of under 1 foot (eg, they can see their parent’s face when being held), and respond to different types of touch (soothing touch and alerting touch). ■X INFANCY Newborns communicate through crying and through behaviors such as facial expressions, body move­ PRENATAL VISIT PRENATAL ments, and movement of their arms and legs. Initially, these behaviors may seem random, but, gradu­ ally, it will be possible to understand this early nonverbal language. ■X Newborns learn to anticipate and trust their world through their parents’ consistent and predictable caregiving (eg, through feeding and how parents respond to their cries). ■X For the first months of life, newborns learn to live in a world that is very different from the womb. In the womb, the baby is in a dark environment, is in a curled­up position with arms and legs close to the body, and feels swaying movements when you walk. The baby is used to a small space with limited movements. Your baby hears constant swishing sounds of the placenta and your heartbeat. ■X During the first month after birth, babies have a lot to learn—how to feed well and how to coordinate sucking, swallowing, and breathing while breastfeeding or feeding from a bottle. They also must learn how to handle the world around them—the sights, sounds, tactile stimulation (touch)—while learning to control their movements. All these are important steps in a young infant’s development. Review of Systems Not applicable. Observation of the Family Dynamic During the visit, the health care professional acknowledges and reinforces positive parent interactions and discusses any concerns. Observation focuses on ■X Who asks questions and who provides responses to questions? (Observe mother’s relationship with her partner, other children, or support people present during the visit.) ■X Verbal and nonverbal behaviors and communication between family members indicating support and understanding, or differences and conflicts. Physical Examination Not applicable. 308 BFG 4TH ED.indb 308 1/20/17 2:47 PM Bright Futures Guidelines for Health Supervision of Infants, Children, and Adolescents Screening Discuss the purpose and importance of the routine newborn screening tests, including newborn blood screening (metabolic, endocrine, hemoglobinopathy), jaundice, congenital heart disease, and hearing, VISIT PRENATAL that will be performed in the hospital before the baby is discharged. Explain that the hospital, state health INFANCY department, and the health care professional work together to ensure that family gets these test results and the appropriate follow­up if any test results are not normal or are not able to be completed before the baby goes home.