The importance of the initial newborn visit

Throughout my early years of caring for infants and children in the out-patient setting, I have noticed an increase in delayed initial newborn visits. The very first visit to the pediatrician’s office, after mother and baby are discharged from the hospital, is extremely important for the well-being of the vulnerable newborn infant. The first visit to the pediatrician’s office should take place three to five days after discharge from the hospital.

One may argue that there are no vaccines given at this initial visit and that the infant can always be brought for a visit if he/she is sick. The problem with this belief is that very often a sick infant may not be easily identified, even by an experienced caregiver. There are also several other important factors to be considered. Let’s discuss a few of them starting with the difficulties of identifying an “ill” newborn.

Adults, adolescents and older children usually exhibit easily identifiable symptoms when there is an illness. Take for example a cough, which would suggest some type of respiratory infection. On the contrary, newborns are more likely to display grunting (which as the name suggests sounds like a shallow repeated grunting sound). This clinical finding may be very difficult for someone other than a clinician to recognize.  Another similar example is abdominal pain. Abdominal pain may point to some type of gastrointestinal or urinary tract infection. Adults and older children can indicate that they are experiencing pain and can often point to and localize the specific area of discomfort. An infant in a similar clinical setting may simply be irritable and may be thought by the parent(s) to be experiencing something benign such as colic.  These are just two examples, but there are several other similar situations.

All newborns are expected to have a period of weight loss in the first few days after birth. However, if the weight loss is noted to be excessive at the time of the first visit, the pediatrician may ask that the infant be re-evaluated at a sooner date than the recommended timeline schedule. Investigations should take place to discover the details of the feeding schedule as well as the method of formula preparation (if powdered formula is being used). In the case of a breastfed infant, the mother may be asked to demonstrate her technique and may be given helpful lactation tips.  In very extreme cases of weight loss or cases where other clinical findings may be present, the newborn may even be re-admitted to the hospital.

Jaundice is a clinical condition which most caregivers will have some knowledge about.  All newborns have their blood checked for a substance called bilirubin. Bilirubin is a yellow pigment formed when hemoglobin is broken down. Hemoglobin is the oxygen carrying component in our blood.  Some amount of bilirubin is present in all babies, children and adults, but levels are higher in newborns. This is the case because of immature clearance (the conversion of this bilirubin into a form which can be easily excreted in the urine) and higher baseline levels of bilirubin because newborns have very high hemoglobin levels.  If the bilirubin level is found to be very elevated, the newborn may need treatment in the hospital prior to discharge. In cases where the levels are more borderline in nature, the bilirubin may simply need to be re-checked. The initial visit gives the pediatrician a chance to follow-up bilirubin levels and make sure they have either stabilized (no longer increasing) or are decreasing. This is extremely important as very elevated levels of bilirubin can cause severe neurological damage and hearing loss.

Another important aspect to be addressed during the initial visit is whether or not the mother has questions regarding her newborn infant. On the other hand she may simply need to be reassured on other concerns. The parents are also given guidance with regards to safety of the newborn infant.  A crucial example here is the pediatric concept of “Back To Sleep”. As the name suggests, the current recommendation is to place infants on their backs to sleep in cribs that are free of an excess of toys or blankets. The implementation of this concept has vastly decreased the number of cases of Sudden Infant Death Syndrome (SIDS). Many new mothers have no awareness or knowledge of SIDS or of the “Back To Sleep” concept.  A new mother may be left to seek answers solely from friends and family. Whilst the advice given may be done with good intention, it may not always be the correct advice based on current medical recommendations.

Lastly, the pediatrician must address the mother’s emotional state. We have all heard of postpartum depression. This is a real psychiatric condition which may affect the capabilities of the mother in caring for her infant. Even in cases where the mother appears to be clinically well and in good spirits, she should be given information about what to expect and how to handle certain situations while caring for her newborn infant. Pediatricians should discuss with parents what amount of crying is considered normal for a newborn and techniques to help with coping. Parents (especially single parents) should be encouraged to have one or two close family members or friends to help them with the care of the infant, even if for just a short period and particularly in stressful situations.

This article is just a brief overview of a few of the fundamental concerns which need to be reviewed at the time of the initial newborn outpatient visit. As can be easily seen, there is a range of fundamental knowledge which must be shared with the parents at this initial visit and it is of great importance that these newborn infants are seen in the recommended scheduling time frame.