Sunday, July 18, 2010

Prenatal/Neonatal Visits

One of the problems that I think faces all doctors is that we lose perspective on the gap between what we know and what most people know. This is particularly obvious in my newborn visits. Like most doctors when doing newborn teaching for a family my goals are
1. Making sure that the family is feeding the kid correctly
2. Making sure that the kiddo is being put to sleep in a safe environment
3. Making sure that they're using a carseat and doing so correctly

Many doctors also use this time to talk about smoke detectors and smoking and carbon monoxide detectors, but I'm a rebel. I will see my newborns again in one week, and it's pretty unlikely anything will change on that front, so I can talk about those things at the two week visit. Why do I care? Because there is only so much information that parents can handle. And instead of talking about smoke detectors, etc. I try to answer the most common parents concerns (both that they have at the newborn visit and that will cause them to come back unnecessarily between the newborn and the two week visit)
1. The equivalence of the hospital brand of formula and the formula that WIC gives out (This is the number one question I get asked)
2. Things normal newborns do -- sleep a lot, get blue hands and feet, breathe funny and strain when they poop (I also try to talk about the line between the normal form of each of these and their pathologic equivalent and when it's worth bringing the kid in for a sick visit.) In infants with dark skinned parents, I like to let them know the skin will get darker (in my patient population fathers worry about mistaken paternity because the newborn is light).
3. Things many normal newborns have -- I let parents know if their kid has a murmur or an umbilical hernia or a hemangioma and that it's normal and how I expect it to change over time.
4. Things that I expect to change before they see me again -- kiddo should start eating more, jaundice should fade, if stools haven't changed from meconium they will, formula kids may get constipated (and that's OK)
5. Things that have already happened and what they meant -- most parents do not understand why their kid got a hepatitis B vaccine in the nursery, what the newborn screen was for, what "that test that they took the baby away to do" was (hearing), or why the baby had black stools at birth and I usually go over some of that.

So by the time we're done going over all of that it's a HUGE amount of information. And that's before I have the nurse come in and give them teaching on how to use a rectal thermometer and how to mix formula. It's a ton of information.

In Ohio, we had new parents come in for prenatal visits. I could talk to them about everything except the particular normal variants that their kid had. Then we would review at the newborn visit, and I would have the time to talk about smoking and home safety and all that jazz and they would have room in their brain to listen. For some unknown reason we don't offer prenatal visits here and I feel like everyone loses out from that.

The time to tell parents how to properly feed a newborn is not when the newborn has already been at home for five days. I'd love to reinforce the need for a jaundice check at day of life three or four, but when parents don't come in to see me until the kid's a week old, at that point there's nothing I can do.

I also think that there's some (a minority) of pediatricians who make up for the lack of prenatal visit and still manage to cram in home safety by sacrificing discussing parental concerns. And I think the reason that happens is that pediatricians lose sight of the knowledge gap. The result is that I've had kids come into the emergency room for glabellar hemangiomas (a normal birthmark. Also called an "angel kiss.") When this happened I asked the parents "Hasn't the kid had that since birth" and they said "well, yes, but it kept getting darker and darker and now he's crying and it's even darker." So I asked, "what did your pediatrician tell you about it?" And they said "oh, our pediatrician never mentioned it."
So it's possible that the pediatrician did give them a great talk on what the hemangioma was and what to expect and the parents didn't remember (because they were on information overload!)
But there are also pediatricians for whom hemangiomas are so routine (about 25-50% of babies have one) that they forget to teach about them. And then, as hemangiomas do, they get darker with time and darker when the kids cry and the parents panic.

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