[...] [Music] [Narrator:] McMaster University, Mohawk College. The Ontario Medical Association, and the Ontario College of Family Physicians. In cooperation with CHCH TV presents Health Care Today. [Music continues] [Well Baby Visit] [Music continues] Here is Dr. Ray Mailloux a family physician and the coordinator of the programmed series dealing with pre-adolescence. [...] [Dr. Ray Mailloux:] Good evening. This is the first of four more programs in the Health Care Today series. With me on the panel tonight are Dr. Gary Gibson, and Dr. Glenn Gibson. We're all members of the same group practice in the nearby area. The, uh, following programs are going to consist of, uh, a program on urinary tract infections. One on respiratory infections, and the fourth one will be dealing with the problems surrounding chronic illnesses in children. The topic this evening is, uh, that of a well baby visit in particular and well child care in general. And we will be watching a film of a well baby exam, which we… we’d like you to look at both the good points and the bad points of this episode of care, and we'll be discussing it later. [Baby crying] [Karen Wilson:] Okay, there we are. [...] He seems to be doing very well. He's gained sixteen ounces since he was here for his last visit. [Mrs. Pat Miller:] Yes, he’s been eating really well. But Karen, I’m wondering about meats. All my friends’ babies have started them by now, [Baby continues to cry] and it says on the schedule that he’s not to be introduced to them yet. What should I do? [Karen Wilson:] Well, Dr. Gibson does like to introduce things systematically, so it’s probably best if you just follow the instruction sheet. [Mrs. Pat Miller:] Yeah. [Karen Wilson:] Okay. [...] [Dr. Gary Gibson:] Morning, [?] [Mrs. Pat Miller:] Hi. [Dr. Gary Gibson:] Where is Shane? All right. Any problems so far that you’re having Pat? [Mrs. Pat Miller:] Absolutely no, no. [Dr. Gary Gibson:] Sounds good. [...] Well, we’ll have a little look at things this morning and see how things are going here. You got the measurements down here Karen? Okay. [...] Okay, sir, well let’s just [?] it first here. [...] Heart sounds are normal, Karen. [...] Hmm, that’s good. Lungs are clear, no problems there. [...] Okay. Fontanel is about two centimeters. [Baby making cooing sounds] [Dr. Gary Gibson:] No nodes in the neck. Shall I have a look in your ears? See if I [?] Shane. We’ll have a peek. There we go. [...] Right is clear. [...] And the left is clear. Got any teeth yet? Probably not. We’ll take a look around. No teeth. Throat’s clear. Palate’s intact. [Exam instrument clanking] Shall we try to have a look at your eyes, too, for a jiffy? [...] Mostly clear on the right. And the same on the left. [...] And the abdomen… [Baby giggles] You’re ticklish already! [?] is not palpable [?] [?] his chest, [?] down [?] here. Good. [...] And femoral pulse is [?] Okay, we’ll check a few reflexes here, too, Shane. [...] Biceps and triceps equal about two plus two. Now okay. These three plus. [...] Ankles, three pluss...still good. Let’s see what you… Tickle. Foot. [...] Toes appear to be down...and [?]. And glabella, positive... [...] Let’s check the testicles. Testicles are both down. [?] is palpable. And hips, normal. Okay, everything seems very good, Pat. Really, there’s no…no problems. Um, this is the third shot today. Karen will administer it in just a minute. And we really don't need to see him again now until he’s a year. That's when the next shot's due. [Mrs. Pat Miller:] Okay. [Dr. Gary Gibson:] So we'll see then. Bye for now, Shane. [Dr. Glenn Gibson:] Well, that's certainly seemed to be a very thorough examination. Um, there were a couple things I'd kind of wonder about, though. [Dr. Ray Mailloux:] One of the things that I’d noticed was that the baby was weighed with his diapers on. Which seems to make it hard to get consistent weighing from one visit to another. I've always felt that you should have them naked when they're… when they’re weighed. The other thing I was noticing was that mother was… seemed to be having some problems with her feeding schedule for the baby. [Dr. Gary Gibson:] We thought we'd probably looked after that adequately Ray, there’s the, uh, as Karen mentioned to her, we had given her instruction sheets, which are actually pretty detailed. Step by step, and uh, you know, in our practice, we’d found it saves a fair bit of time to have them already have it written down. [Dr. Glenn Gibson:] Well, if you're gonna be that rigid with your feeding, I think you need some sort of instruction sheets to try and keep mother straight. [Dr. Ray Mailloux:] You don't like that idea then? [Dr. Glenn Gibson:] No, I really don't go along with uh… with that sort of approach. [Dr. Ray Mailloux:] Well, let's see how you handle the uh… that baby visit. [...] [Baby cooing] [Baby fussing] [Karen Wilson:] He seems to be coming along very well Pat. He’s gained sixteen ounces since he was here for his last visit. [Mrs. Pat Miller:] Yes, he’s been eating really well. Um, Karen, do you think that it’s time that I started him on the meats? [Karen Wilson:] Well, I’ll tell you, why don’t you wait till Dr. Gibson comes in and you can discuss it with [?]. [Baby cooing] [Dr. Glenn Gibson:] Hi there, sorry I'm late. [Mrs. Pat Miller:] Oh, that’s okay. [Dr. Glenn Gibson:] How’s everything going? [Karen Wilson:] Oh, he seems to be coming along really well. He’s gaining about a half an ounce a day. But mom does want to ask a few questions about his feeding. [Dr. Glenn Gibson:] What sort of things, Pat? [Mrs. Pat Miller:] Oh, everything’s fine, but do you think I could start him on meat? [Dr. Glenn Gibson:] Meat? What all have you got him on so far? [Mrs. Pat Miller:] Well, he’s still on formula, of course, and I give him Pablum every day, and I’ve started him on fruit. [Dr. Glenn Gibson:] How about vegetables? [Mrs. Pat Miller:] Well, I’ve tried to give him vegetables, but he doesn’t really like them. [Dr. Glenn Gibson:] Okay. Well, why don't you try him on some meat now, and then maybe we can try the vegetables again later on. [...] [Dr. Glenn Gibson:] That's my approach. I really don't think you should be rigid about the feeding schedules at all. [Dr. Gary Gibson:] I see, you’re not using handouts then at all really for feeding instructions for mother. [Dr. Glenn Gibson:] No, I think if you're too structured with it, that really all that leads to is anxiety in the mother. She gets upset because her baby doesn't quite fit the schedules. And it really is more problems than it's worth. [Dr. Ray Mailloux:] Well, shall we see where you go from there, then? [Dr. Glenn Gibson:] Any other troubles? [Mrs. Pat Miller:] No, everything’s quite fine. [Dr. Glenn Gibson:] How about his bowels? [Mrs. Pat Miller:] Oh, they’re very regular. [Dr. Glenn Gibson:] Good. And sleeping? [Mrs. Pat Miller:] Oh, he’s very good. [Dr. Glenn Gibson:] Is he up at all at night? [Mrs. Pat Miller:] Yes, he is. Um, I put him bed at 8 but he gets up three and four times after midnight. [Dr. Gary Gibson:] Well, that's odd, then. Then she didn't tell me about the… that sleep problem when she was talking to me. [Dr. Ray Mailloux:] Well, she didn't really tell Glenn about it either, but he asked rather more specific questions. [Dr. Glenn Gibson:] I think a lot of mothers are really afraid to ask things like that. And unless you bring up the subject, they just won't tell you about it. [Dr. Ray Mailloux:] Where, um… Let's see where you go from there, then, Glenn. [...] [Dr. Gary Gibson:] The um, sleep pattern is the thing that, uh, probably I missed very much in that discussion. And, uh, well, it probably is an important thing, because mother’s always gonna get quite tired out having to get up that often through the night. I suppose one thing might do is to give the mother, give the mother… I'm sorry, give the child, a night sedative, maybe mother, too, but give the child something like phenobarb or [?], something of that sort. [Dr. Glenn Gibson:] No, I certainly… certainly wouldn't go along with that. I think, uh, sleep disturbances in the child very often indicate problems in the family, not so much with the baby, but with the family as a whole. And I think things like that you shouldn't just pass over. You should go into further and try and find outwhat's going on with the family. One other thing with the examination, you didn't seem to be checking for milestones. [Dr. Gary Gibson:] Uh, you're referring to something like the Denver grid then that has a sort of large number of motor development as well as social functions. It’s… it's really a very time-consuming thing, and I normally don’t… don't bother doing anything like that at all. And you saw the examination that I do, which is obviously fairly thorough. But the other, it takes quite a bit of time. [Dr. Glenn Gibson:] Well, here, let me show you, uh, show you what I mean. [...] There we go, that's a good guy. Here, let's turn you over, Shane. Can you turn over there? That's the way. [Shane cooing] That’s the way. Can you see my light? You can see it. You see my light? You see my light? You look over here. [...] That's the way. Okay. Now, let's see, by four months, he should be… Uh. When did he learn to roll over? There in really just a few seconds, you've established that he has in fact met four of his major milestones for four months. He's holding his head up on his elbows. Uh, he's turning his head to follow a light. He's smiling. And he has learned to roll over. [Dr. Ray Mailloux:] I guess you would only need to go into a detailed comparison with the Denver grid if you thought that there were any problems. [Dr. Gary Gibson:] I see. Well it’s… it's certainly a good points. I did an awful lot of neurological investigation. It really didn't tell me the milestones, and I suppose I probably shouldn’t… should use more of that examination time to check milestones rather than every other reflex I can think of. [Dr. Glenn Gibson:] I think that would certainly be a worthwhile change from the routine you showed us. [Dr. Ray Mailloux:] Glenn, are there any other differences in the way you do things? [Dr. Glenn Gibson:] I don't think there are any major changes, not as detailed as Gary's. But other than that, basically the same sort of physical examination. [Dr. Ray Mailloux:] Gary, I noticed that you arranged to see him when he was a year old, which is a full eight months away. Um, let's see what you do with that, Glenn. Okay. [Dr. Glenn Gibson:] Okay. [...] [Dr. Glenn Gibson:] There we go, Shane. Let’s wiggle you around here. [Baby crying] That's good. Okay, well, everything certainly seems to be fine, Pat. Uh, now, he’s due for his third needle today, and that’ll be the last one till he’s, uh, until he’s a year old. I’d kinda like to see him, though, around eight months or so just to see how things are doing, or sooner of course if there’s any troubles. Any other questions? [Mrs. Pat Miller:] No, the feeding was the only problem I had. [Dr. Glenn Gibson:] Good. Okay, well, let's go ahead and give it a shot today and we're all set then. [Mrs. Pat Miller:] Okay. [...] [Dr. Ray Mailloux:] So you're gonna bring him back when he's eight months, which is really before he's due for another shot? [Dr. Glenn Gibson:] I think so. I get pretty well all of them back at eight months and sometimes even… even a couple of times between four months and a year, if there are any… any problems showing up. [Dr. Gary Gibson:] So you're… you're really gauging it a bit then… then on how… how much trouble the mother is having or if there are any concerns about developmental milestones. Adjusted fairly flexibly, do you? [Dr. Glenn Gibson:] Pretty much. If the child was doing perfectly well and has been meeting all the milestones and so on, then you're unlikely to run into problems during that time. But if there are any indications early on that things aren't going well. I certainly get those back in to keep checking the milestones and just see if they are getting further behind or what's happening. [Dr. Ray Mailloux:] So on a routine, then, you're… you're asking them to bring the baby in once between those… the last… the early needles and the next one due in a year. [Dr. Glenn Gibson:] Right, that would be my standard routine. [Dr. Gary Gibson:] This can obviously be, you know, be fluctuated a fair bit, depending on what your own immunization schedule is, too. And there’s all kinds of different systems and probably the exact visit times can be adjusted to your own pattern, too. It might end up being at two, four, six months, and nine, or something like that, I suppose, too. [Dr. Ray Mailloux:] I think one of the things we're trying to do is… is to sort of get away from the physical examination and the giving of shots as a goal for… for the visit and concentrate on how well this child is doing in developing. [...] [Dr. Gary Gibson:] The place of the Denver grid, I think we should probably talk about a little bit more. As we implied in our earlier role-playing parts, the Denver grid is obviously a fairly complex system. And there are all kinds of the drug companies in the formula companies that make them. Some of them shortened up and some not, but… and generally fairly complicated. The other part about the Denver… Denver grid that we haven’t commented on is the… sort of the variation of the milestones. Um, how do you handle that part, Ray? [Dr. Ray Mailloux:] I try to keep in mind some of the major ones such as, oh, smiling, being able to roll over. Relating to you when… when you’re… as Glenn did, when trying to deal with them. And by the second or the third visit, well they should certainly be doing those things. So if they're not, you know, you're only keeping a few things in line out of the big, massive things on the grand Denver grid. And they're the ones that might… they might begin to smile at six m… six weeks. But if they're not doing it by three months, it certainly really strikes you, so those of the ones you keep in mind. [Dr. Gary Gibson:] Starts getting worrying about then. [Dr. Glenn Gibson:] And then you’d, what, go into a more detailed use of the Denver grid if… if you found something like that, that wasn't doing what he should. [Dr. Ray Mailloux:] You could bring them back again, set up to get some time to do it, either that or send them to someone else who can do it. Get a good assessment of whether they are behind or not. [Dr. Gary Gibson:] All right. [Dr. Ray Mailloux:] The same kind of thing that, uh, say when you bring them in at eight months. By eight months, you expect the child to be sitting. Perhaps beginning to pull himself up. Um, if he's not crawling should be upon his hands and knees. And sometimes they're not doing that at that particular point in time, you certainly begin to wonder. Where if you don't see them for a year, you've missed four or five… four or five months and you're in your development scale. [Dr. Gary Gibson:] I think probably from a practical standpoint, thinking back to my own training days that I was really not given any kind of indicator of milestones, that I was given a great long sheet, and much like the Denver grid only at that time, just printed up. Saying this is what the baby should be doing at two months, three months, four months. Really a hopeless business to try to remember. And I remember thinking back in my early days of training and practice. That it was just impossible and almost gave up doing it. [Dr. Ray Mailloux:] It certainly makes a big difference when you have kids yourself to help you remember them. [Dr. Glenn Gibson:] The other thing with regard to the actual physical examination, just how thorough an exam do you think is justified at each of these well baby visits? [...] [Dr. Ray Mailloux:] You do thorough examinations presumably when the baby is born. And maybe once or twice more in the office. But there's so many of the things that once you establish that they’re normal, they're not really gonna change again. If you find that femoral pulses are there, well, you're not going to expect them to disappear. They don't really need to be checked each time. Some things do change. Heart murmurs can develop in the… in the first few months that weren't there at the beginning. [Dr. Gary Gibson:] Frequently not therethe first… first few weeks, even, right. [Dr. Glenn Gibson:] What do you do about recording these visits now, when the kids are in? Do you write down a full page for every visit or what’s… What’s your routine? [Dr. Ray Mailloux:] I… again I sort of keep a number of key things in mind, then. Things that I check each time. Such as, oh, the hips for any evidence of congenital hip disease and so on. I try and record those in such a way that I, quickly glancing back, I can see that it was done last time and it was normal, and if there are any changes then they stand out this time. I feel strongly that the records are a bit of a problem, you know. If you're going to do complete examinations when the baby's born in the hospital and you're gonna assess and record Apgar scores in the hospital. Um, I find that often, or easily anyway, they don't get back into the chart for reference back due in a few months. [Dr. Glenn Gibson:] This is particularly true in a group set-up like ours. Where there are lots of occasions when the child is being seen by a different doctor for some reason, and even if you remember that that was normal on the last visit, it's not going to do the examining physician much good at that point. [Dr. Gary Gibson:] It's got to be written down someplace, or it’s… or it’s of no use at all. For those of us in this practice, know that we've almost annually have a fight about what kind of records we're going to use for well baby visits. You're always in this battle of trying to keep the numbers of pieces of paper down. There are all kinds of flow sheets available, which are fine for following milestones and well baby care, and then you get a sickness episode thrown in. And that is… Does that go onto another page? And you keep growth percentile charts, uh, separate on another page as well. It's really tough. [Dr. Ray Mailloux:] I personally would still like to see us using a checklist, at least for the identifiable well baby visits. [Dr. Glenn Gibson:] This is the reason we have an annual discussion is to try and sort this out. [Dr. Ray Mailloux:] Glenn, you mentioned then, somewhere along the way, that you were gonna pursue… that you’d like to pursue things like the mother’s mentioning of sleep patterns. Um, what did you mean by that? [Dr. Glenn Gibson:] Well, I think… I think things like that are often a… as I mentioned a sign that there are other troubles in the family. Not so much just with the baby itself. And I think it, uh, it's worth pursuing those to some extent. Just to see what is going on in the family. [Dr. Gary Gibson:] Is… Is sleep the only… only thing that you find, Glenn, that gets disturbed? [Dr. Glenn Gibson:] Well, no, certainly in this four month age group that we're talking about tonight that… that's probably the commonest disturbance is in the sleeping. But for different age groups, I think you'll find there are different things that do get, uh... disturbed when the child is upset about something. [Dr. Gary Gibson:] It took me a couple of years in the practice to start recognizing what was happening, but I agree very much. I think there are almost characteristic functions that go haywire at, uh, in different age groups and typically the sleep is the main one at this age. Maybe even colic may in fact be one of the indicators of… of stress in the family of one sort or another in this age group. And then you get on a little bit further, say the one- to two-year-olds, it's more often that they won't go to sleep at night. They stay up late and maybe make a great fuss about eating. And that's also the same kind of a triggering, should trigger us anyway, to think what's going on? [Dr. Ray Mailloux:] I think we have to try not to overreact, you know. If I see a mother who's got three kids at home and each one of them is headed up five times every night until they were a year of age um, I tend not to rock the boat too much. And she's already been through it three times, and that's the way she seems to want it. [Dr. Ray Mailloux:] And certainly if it’s a young mother, though, on a young marriage. I'll take a closer look at it. [Dr. Glenn Gibson:] Sometimes you don't actually have to get into any great counseling episode. It's often just, particularly in the young mothers, that they don't know what is normal. They don't know what to expect, and they don't know what to do about it. And often a few very directive suggestions is all you need to do. And things will be fine. [Dr. Gary Gibson:] How do you… How do you decide when you're going to just either let it pass off as being a temporary problem or when are you gonna use behavior modification. Which is maybe just leaving… letting the baby yell at night and keeping mother and dad calm. Or going into much more deeper things, right? You're our expert on family dynamics and family therapy. [Dr. Ray Mailloux:] There's no hard, fast answers to that kind of thing. I, as Glenn said. You try the simple things first, and you make sure that the parents are aware of what… what might be expected of a baby. You start to talk to a mother like that, and if you find that she's up three or four times a night. When she's maybe felt, really, there's nothing particularly wrong with the baby, and she picks it up for a few minutes or gives it its soother and it goes back to sleep and wakens another hour later. And then if you find that the husband is putting pressure on the mother. To get up and shut that kid up so he can sleep for the rest of the night. [Dr. Gary Gibson:] Sort of aggravating the stress, even further… [Dr. Ray Mailloux:] You begin to wonder if she's getting enough support and then of… sometimes you get into an area like that, and when you start asking about their relationship, you get into a whole can of worms. [Dr. Gary Gibson:] The other thing, I keep seem to be the one to talk about practicalities of time and so forth. But what about the use of the time in a visit? You know, if you start getting into this kind of thing, isn’t that going to shoot most of the time for the visit? [Dr. Ray Mailloux:] Well, it brings you to a whole sort of philosophical point as to just what you should be doing. Should you be putting out time energy and digging into the baby's patterns and the parental patterns, the family patterns and so on. Or should you be just doing the physical and organic [?] part of it? [Dr. Glenn Gibson:] Certainly, if you dig deep enough in any family, I think you're gonna find troubles. [Dr. Ray Mailloux:] Well, it… every family has difficulties at times. [Dr. Glenn Gibson:] It's probably, I guess, if it's causing a significant upset in the whole family, then that's the kind of thing that I certainly go after. [Dr. Ray Mailloux:] All right. [Dr. Gary Gibson:] We, uh, we didn't quite finish sort of rattling off the vegetative functions, and perhaps before we wind up, we should mention the slightly older groups. As we're not just talking about well baby visits. Um, certainly Ray’s last point of using the time I very much agree with, too. We’ve… we've deliberately structured the program this evening to show you extremes. Not necessarily either one of them being totally right or wrong. But we feel that more of the time and more directed questions probably are indicated. Just to… Just to finish off. Sorry, I'm going to say that as you get into the middle age groups, it's probably more commonly you start getting the tummy ache, headache problems. Maybe toilet training in the two- to three-year-old's. And then more and more difficulties with GI and headaches and so forth up to the early pre-teens. Those always, I think, should be a tip-off that there may be either child stresses or… or family difficulties as well. [Dr. Ray Mailloux:] When we initially sat down to consider the content of this program. We thought there were two areas we really wanted to deal with. One was that of considering de-emphasizing the physical examination part of the well childcare and the immunization part of it. And putting our money and our energy on the monitoring of the growth and development in their achievement of milestones. And the other area we wanted to look at was to consider how appropriate is to dig, um, quite deep into the relationship between the mother and the child and the, if necessary, the mother and the father. It can be time consuming. It can also be very interesting. Another thought we'd like to leave you with is where the nurse practitioner could fit into well childcare. In our own set-up, we just not set things up so that we can… we can do this. But certainly the nurse practitioner might be able to do a lot of these things while we were dealing with some illness in another room. As you've probably been aware, the initial film parts were role-played, and we'd like to thank our nurse, Karen Wilson. And mother, Mrs. Pat Miller and baby Shane for their part in it. We hope that we've given you something to think about with this program tonight. [Narrator:] If you are interested in participating in the evaluation of the Health Care Today television programs, or if you would like further information on the program's plan for this year. Please contact Health Care Today. Care of Jan McHugh: 2E4 McMaster Medical Center, or phone 525-9140. Extension 2489 or 2110. [Music] [Narrator:] Health Care Today was produced in cooperation with CHCH TV. McMaster University. The Ontario Medical Association. Mohawk College. The Ontario College of Family Physicians. And the Hamilton Academy of Medicine. [Photography and Graphics; Audio Visual Services, McMaster University] [Music continues]