Well-baby Care on the CCFP exam

Approach

• Use the World Health Organization (WHO) Growth Charts for Canada. They replaced the US Centers for Disease Control and Prevention (CDC) charts in 2010 and are built on breastfed babies.
• Under 2: measure length lying down, weight, and head circumference at each well visit. From 2: measure standing height.
• Judge weight against size with weight-for-length under 2. BMI-for-age starts at 2.
• Preterm baby: plot at corrected age, which is birth age minus the weeks born early. Keep correcting until at least 24 to 36 months.
• Preterm charts, such as Fenton, belong to the neonatal unit and early after discharge. After that, use the WHO charts.
• One point shows size only. Read the trend over several visits before you call it a problem.

Approach

• Hold a vaccine after anaphylaxis to a past dose of it, or to one of its parts. Get expert advice after a suspected moderate or severe allergic reaction.
• Egg allergy is no reason to hold MMR or flu vaccine. No skin test is needed first.
• A mild illness, with or without fever, is no reason to delay. Neither is a febrile seizure after a past vaccine dose.
• Severely immunocompromised: no live vaccines that replicate, such as MMR, varicella or rotavirus. Non-live vaccines can usually be given.
• High-dose steroids are prednisone 2 mg/kg a day, or 20 mg a day over 10 kg, for 14 days or more. Wait at least 4 weeks after stopping before a live vaccine.
• Household contacts get their routine vaccines, MMR and varicella included. A baby there can have rotavirus vaccine, with careful handwashing for 4 weeks.
• Stable preterm babies: vaccinate at chronological age, on the same schedule as term babies. Do not delay.

Approach

• Ask what the mother wants: how long she hopes to breastfeed, and what she wants to change.
• Support breastfeeding to 2 years and beyond, for as long as mother and baby want.
• A breastfed baby at low risk needs vitamin D, 400 IU a day, through the first year.
• From about 6 months, add iron-rich foods: meat, meat alternatives, iron-fortified infant cereal.
• If the baby breastfeeds to sleep, wipe the gums and new teeth.
• Night feeds on demand past 12 months raise the risk of tooth decay.
• Weaning is her choice.

Approach

• Work through the flow sheet's list for that age, so no topic is missed: feeding, development, vaccines, sleep and safety.
• First foods at about 6 months should be rich in iron: meat, meat alternatives, iron-fortified infant cereal.
• High-risk baby, meaning eczema or another allergic condition in the baby, a parent or sibling: offer peanut and egg around 6 months, not before 4. Then offer them a few times a week.
• At the first tooth, brush twice a day with a rice-grain smear of fluoride toothpaste. Book a first dental visit by 12 months.
• If the baby breastfeeds to sleep, wipe the gums and new teeth.
• Fever: check the parent's dose of acetaminophen or ibuprofen against the child's weight.
• Name the vaccines due at the next visit.

Approach

• Ask how an older child is taking the baby: jealousy, rough play, acting younger.
• Ask how each parent's role has changed: sleep, work, leave, and who does what.
• Ask who helps: grandparents, other family, friends. Ask whether family advice causes strain.
• Canada's task force advises against a scored depression questionnaire for every mother in pregnancy and the year after birth.
• Ask about mood and well-being at visits instead. The task force expects that as part of usual care.
• Low mood, conflict or no support: plan follow-up and local help.

Approach

• Do not dismiss the family. Withholding care is unlikely to change their minds and does not help the child.
• Start presumptively: the baby is due for vaccines today. That wins more acceptance than asking what they want to do.
• If they hesitate, use motivational interviewing: open questions, affirming, reflecting, summarizing.
• Ask what worries them. Do not assume it, and do not overestimate it.
• Explain that some complications of these diseases are serious and still cannot be treated. Use plain words and true stories.
• A healthy unvaccinated child can spread disease to family and beyond. Waiting for an outbreak is often too late.
• Deal with shot pain up front.

Approach

• Say plainly where the evidence is clear, where it is mixed, and where it has changed.
• Give benefits and harms in the same plain terms. Then ask what matters to the family.
• Allergenic foods: in 2013, high-risk babies were advised 6 months of breastfeeding alone. Since 2019, the advice is to offer them around 6 months, not before 4.
• Check the date on any guideline you quote. Chart what you discussed and what they chose.

Approach

• At each visit in the first 2 years, check for risk of iron deficiency.
• Higher risk: low income, a mother with anemia, few iron-rich foods, preterm or under 2500 g, chronic illness. Screen with a complete blood count and ferritin (a blood test of iron stores).
• Babies 7 to 12 months need about 11 mg of iron a day. Offer iron-rich foods from about 6 months.
• Cow's milk: wait until 9 to 12 months. Limit it to 750 mL a day in the first year, then 500 mL a day from 1 to 2.
• Breastfed baby at low risk: vitamin D 400 IU a day through the first year. Breastfed First Nations, Inuit or Métis baby at high risk, such as one living north of 55° latitude: 800 IU a day in the first year. No routine blood level.
• Ask about bottles, juice and sweet snacks. Each one raises the risk of tooth decay.
• A vegan or restricted diet needs a full diet review, even when growth is normal.