What are the key components to assess and address during a 4-day initial well child visit as a Primary Care Physician (PCP)?

4-Day Well Child Visit: Essential Components

At a 4-day well child visit, you must conduct a comprehensive physical examination, assess feeding and jaundice, verify newborn screening results, ensure follow-up is established with the medical home, and screen for maternal postpartum depression and social risk factors. 1

Primary Purpose of This Visit

This visit serves as the critical early follow-up for newborns discharged before 48 hours of life, designed to detect conditions that may cause readmission and ensure proper establishment of care. 1, 2

Physical Examination Components

Growth Assessment

• Weigh the infant and compare to birth weight—assess for adequate weight gain or concerning weight loss (>7-10% is concerning). 1
• Measure length and head circumference, plotting on appropriate growth charts. 3

Hydration and Jaundice Assessment

• Assess hydration status by examining skin turgor, mucous membranes, fontanelle fullness, and activity level. 1
• Evaluate degree of jaundice through visual inspection and consider serum bilirubin if clinically indicated. 1
• Obtain historical evidence of adequate stool and urine patterns (should have at least 6 wet diapers and 3-4 stools per day by this age). 1

Head-to-Toe Examination

• Examine fontanelles, head shape, and presence of any abnormalities. 3
• Perform red reflex testing to detect ocular media abnormalities. 3
• Assess skin color, perfusion, and presence of rashes or lesions. 3
• Examine tympanic membranes and assess nares for patency. 3
• Examine oral cavity including palate and tongue. 3
• Auscultate heart for rate, rhythm, and murmurs. 3
• Auscultate lungs and assess respiratory rate and pattern. 3
• Palpate abdomen for organomegaly, masses, or tenderness. 3
• Assess umbilical cord site for healing and absence of infection. 3
• Examine external genitalia and assess urinary stream. 3
• Examine hips for signs of developmental dysplasia. 3

Neurological Assessment

• Evaluate tone, posture, and primitive reflexes. 3
• Assess spontaneous movements and overall activity level. 3

Feeding Assessment

This is a critical component at this visit. 1

• Review feeding patterns and technique in detail. 1
• For breastfed infants, observe adequacy of position, latch, and swallowing. 1
• Assess frequency and duration of feeds (should be feeding 8-12 times per 24 hours). 1
• Provide or refer for lactation support if evaluations are not reassuring. 1

Laboratory and Screening Review

• Review results of newborn metabolic screens performed before discharge. 1
• Review newborn hearing screening results if not previously done. 3
• Perform additional screenings as clinically indicated (e.g., serum bilirubin if jaundice present). 1
• For infants born to HBsAg-positive mothers, ensure proper hepatitis B vaccine and immune globulin administration. 3

Immunization Review

• Verify hepatitis B vaccine was administered per schedule. 3
• Ensure age-appropriate immunizations are planned according to CDC recommendations. 3

Maternal and Family Assessment

Maternal Postpartum Depression Screening

• Screen for maternal postpartum depression—this is a critical component often overlooked. 1
• Use a validated screening tool (e.g., Edinburgh Postnatal Depression Scale). 4

Social Risk Factors

Assess for the following risk factors that may delay discharge planning or require intervention: 1

• Untreated parental substance use or positive toxicology results. 1
• History of child abuse or neglect. 1
• Parental mental illness. 1
• Lack of social support, particularly for single, first-time mothers. 1
• No fixed home or housing instability. 1
• History of domestic violence. 1
• Adolescent mother. 1
• Barriers to adequate follow-up (lack of transportation, no telephone access, language barriers). 1

Mother-Infant Interaction

• Assess quality of mother-infant attachment and details of infant behavior. 1
• Observe caregiver-infant interaction during the visit. 3

Anticipatory Guidance

Safety Education

• Reinforce safe sleep practices: back to sleep, firm surface, no co-sleeping. 1
• Discuss appropriate use of car safety seats (rear-facing until age 2 or until height/weight limit reached). 1, 4
• Car seats should be used only for travel, not for positioning in the home. 1

Infant Care

• Provide guidance on bathing, skin care, and temperature measurement. 3
• Discuss normal newborn behaviors and crying patterns. 3

Feeding Guidance

• Encourage continued breastfeeding with specific support as needed. 1
• Discuss feeding frequency and recognition of hunger cues. 4

Establish Medical Home

• Verify the plan for ongoing health care maintenance, including method for obtaining emergency services. 1
• Schedule next preventive care visit (typically 2-month well child visit). 1
• Ensure family knows how to contact the practice for concerns. 1

Documentation

• Document all findings, screenings reviewed, anticipatory guidance provided, and follow-up plans. 1
• Note any concerns requiring additional follow-up or subspecialty referral. 1

Common Pitfalls to Avoid

• Failing to directly observe breastfeeding when there are concerns about weight loss or feeding adequacy—observation is essential, not just asking about it. 1
• Missing jaundice assessment or failing to obtain bilirubin level when clinically indicated. 1
• Not screening for maternal postpartum depression—this affects infant outcomes. 1
• Overlooking social risk factors that may compromise infant safety. 1
• Not ensuring newborn screening results have been reviewed and acted upon if abnormal. 1