24: 4-week-old female with fussiness Flashcards
Apgar Scores
The Apgar score is determined by evaluating the newborn baby on five simple criteria (Appearance, Pulse, Grimace, Activity, Respiration) on a scale from zero to two, then summing up the five values thus obtained.
Scores 3 and below are generally regarded as critically low, 4 to 6 fairly low, and 7 to 10 generally normal.
The test is done at one minute and five minutes postpartum.
Supporting Breastfeeding – Understanding Expected Birth Weight Fluctuations, Typical Delay of Milk Production, and the Need for Social Support to Sustain Breastfeeding
Normal infants will lose up to ten percent of their birth weight in the first several days after delivery. By two weeks of age, expect an infant to have returned to birth weight.
Breastfeeding mothers, particularly those lactating for the first time, may have delay of milk production in the first few days following delivery, although colostrum, the most concentrated and rich human milk, is present from the time of delivery on. Significant volume of milk production typically begins around 48-72 hours following delivery, but some perfectly healthy normal lactating women may not establish a full milk supply until several days following delivery. Infants are well adapted to tolerate this delay in volume delivery in most cases, and the concentrated nutrition of colostrum helps tide them over until milk supply is established.
Four-Week-Old Developmental Milestones
Babies by 4wks of age have begun to be much more alert and responsive. They will begin to bring their hands within range of their eyes and mouth and some of their jerky body movements will have begun to smooth out. They will listen when you talk to them, focus on you when you are holding them at a distance of eight to 12 inches, and it will be clearer that they are responding to their mother or caregiver. Four week olds can move their head from side to side when lying on their stomach, will continue to have their head flop back if unsupported, and keep their hands in tight fists.
Normal 4wk olds’ eyes will continue to wander, and perhaps cross, but less often than in the immediate newborn period. They show preference for the human face, have mature hearing, show recognition for some sounds, such as the mother’s voice (even if she is not within their view) and may turn toward familiar sounds or voices.
Rooting Reflex
The rooting reflex is elicited by stroking a newborn’s cheek, which prompts the infant to turn her head toward the stimulus. This reflex is present at birth and assists in breastfeeding. It disappears at around four months of age as it gradually comes under voluntary control.
Wessel definition - Rule of Three
Unexplained paroxysmal bouts of fussing and crying that lasts at least three hours a day, at least three times a week, for longer than three weeks.
Healthy Infant Crying Behavior
2 weeks of age
2 hours/day
6 weeks of age
3 hours/day
3 months of age
1 hour/day
Screening Pregnant and Postpartum Women for Depression
Postpartum depression affects 7-15% of women in the first three months postpartum, and up to 22% of women in the 12 month period following childbirth, with an incidence of major postpartum depression of 5-8%.
Postnatal Depression Screening
PHQ-2 (Patient Health Questionnaire-2 questions):
- -The shortest and most readily utilized rapid screen for depression validated to have a sensitivity of 96% and a specificity range from 57-78%.
- -If the additional question, “Is this something you would like help with?” is added to the two questions about diminished mood and pleasure in doing things, the specificity increases to 94%. This data applies to general adult screening.
- -Most authors recommend using the expanded version, the PHQ-9 as a follow up screen if the PHQ-2 answers are both positive.
Edinburgh Postnatal Depression Scale
A screening instrument designed specifically for postpartum depression
Postpartum Blues vs. Depression
>>Postpartum blues Most women (up to 85%) get what's known as 'the blues,' which usually occurs soon after childbirth, often peaks around the fourth and fifth day, and subsides by around ten days; it's marked by mood swings which can be significant, tearfulness, irritability, and fatigue, and many women associate it with their milk coming in as lactation gets established.
> > Postpartum depression
Postpartum depression can occur any time from delivery to several months later and is more serious. It is marked by traditional signs and symptoms of depression. Most clinicians feel that postpartum depression can be diagnosed up to six months after childbirth. The formal DSM-V criteria describe potential onset of postpartum depression during the peripartum period and up to 4 weeks following childbirth. Having a history of depression or a previous episode of postpartum depression puts a woman at increased risk of developing postpartum depression.
> > Postpartum psychosis
Remember that there is a severe end of the spectrum of postpartum mood problems known as postpartum psychosis; this is quite rare (only 0.2%) but can be quite rapid in onset following childbirth and is marked by true signs and symptoms of psychosis.
Recommended Management of Postpartum Depression
- -community support
- -counseling
- -medication
Colic Treatment
Breast milk is by far the most readily digestible, efficient, and healthy food for the baby.
Many studies of babies with colic over many years have proven that, in general, switching formulas, or going from breast milk to formula does not help except in certain rare conditions. In fact, there is evidence that frequent formula changes in attempt to treat colic might make the symptoms worse.
Products like simethicone (Mylicon), which eliminates gas, and dicyclomine (Bentyl), which slows down the activity of the gut have been studied, but have no solid evidence supporting their efficacy or safety. Recent research suggests that probiotics might be helpful but requires further study.
Differential of Fussy Infant Most likely diagnosis
Colic affects approximately 20-25% of all infants. Symptoms typically begin around the age of two weeks, peak at about six weeks, and gradually improve over the next several weeks, with most infants free of symptoms by twelve weeks of life.
Differential of Fussy Infant Less likely diagnoses:
- -pyloric stenosis
- -intussusception
- -allergy to breast milk
- -gastroesophageal reflux
- -infection
- -FTT
Pyloric stenosis
Pyloric stenosis is the most common cause of nonbilious vomiting in infants.
The incidence is 1-3/1,000 infants in the US. The male to female ratio is 4:1.
Genetic predisposition occurs in 20% of males and 10% of females whose mother had the condition. The etiology is unknown.
It presents most typically after three weeks of age and up to five months. It may present as early as the first week of life.
Vomiting may be projectile.
Diagnosis is made by palpation of a firm, mobile, 2 centimeter long, olive-shaped pyloric mass located above and to the right of the umbilicus in the mid-epigastrium beneath the liver edge, present in about 70% of cases.
Ultrasound is 95% sensitive for diagnosis and used when presentation suggests the diagnosis but a mass is not palpated.
Treatment is surgical.
Intussusception
Intussusception is a condition in which a portion of the alimentary tract is telescoped into an adjacent segment, most often ileocolic.
It is the most common cause of intestinal obstruction in infants between the ages of three months and six years of life.
More than 80% occur before the age of 24 months; it is rare in neonates, and the male to female ratio is 4:1.
Incidence is 1-4/1,000 live births.
Intussusception is characterized by sudden onset of severe, paroxysmal, colicky pain, recurring at frequent intervals. There may develop progressive lethargy, weakness, fever, and shock if it is not diagnosed and treated.
