What are the primary recommendations for an 11-day-old newborn visit?

11-Day-Old Newborn Visit: Primary Recommendations

An 11-day-old newborn visit should focus on weight assessment with intervention if >7-10% below birth weight, direct observation of feeding technique, jaundice evaluation with bilirubin measurement if indicated, maternal postpartum depression screening, and verification of newborn screening results. 1, 2

Physical Assessment Priorities

Growth and Hydration Status

• Weigh the infant and compare to birth weight—weight loss exceeding 7-10% requires immediate intervention. 1, 2
• Measure length and head circumference, plotting on WHO growth charts 3
• Assess hydration by examining skin turgor, mucous membranes, fontanelle fullness, and activity level 1, 2
• Document vital signs including axillary temperature (36.5°C to 37.4°C), respiratory rate (<60 breaths/minute), and heart rate (100-190 bpm when awake) 3

Jaundice Assessment

• Visually inspect for jaundice and obtain serum bilirubin if clinically indicated 1, 2
• Consider major risk factors: jaundice in first 24 hours, blood group incompatibility, gestational age 35-36 weeks, previous sibling requiring phototherapy, exclusive breastfeeding with poor intake, and East Asian race 1
• Measure both total and direct bilirubin levels if jaundice is present 3

Complete Physical Examination

• Examine umbilical cord for healing and signs of infection 1, 3
• Assess skin condition and newborn genital health 1
• Palpate fontanelles for size and tension 3
• Perform red reflex examination 3
• Auscultate heart and lungs for abnormalities 3

Feeding Evaluation

Direct Observation Required

• Directly observe breastfeeding technique, assessing adequacy of position, latch, and swallowing—this is non-negotiable. 4, 1, 2
• For bottle-feeding infants, verify coordination of sucking, swallowing, and breathing 2
• Review feeding frequency—infants should feed 8-12 times per 24 hours 1, 2

Feeding Support and Intervention

• Provide or refer for lactation support immediately if feeding evaluation is not reassuring. 4, 1, 2
• Document adequate stool and urine patterns 4, 1
• Give pain relief 20 minutes prior to feeding if oral blistering is present (relevant for specific conditions) 4

Laboratory and Screening Review

Mandatory Verifications

• Review results of newborn metabolic screens performed before discharge 4, 1, 2
• Verify hearing screening completion 1, 2
• Review maternal laboratory results including syphilis, hepatitis B surface antigen, and HIV status 1, 2
• Confirm pulse oximetry screening for congenital heart disease was completed 1
• If initial metabolic screening was performed before 24 hours of milk feeding, repeat testing is required. 1

Maternal and Family Assessment

Postpartum Depression Screening

• Screen for maternal postpartum depression using a validated screening tool—this is a critical component often overlooked. 4, 1, 2
• Assess quality of mother-infant attachment and infant behavior 4, 1, 2

Social Risk Factor Assessment

Screen for the following risk factors that may require social services intervention: 4, 1, 2

• Untreated parental substance use or positive toxicology results
• History of child abuse or neglect by any anticipated care provider
• Parental mental illness
• Lack of social support, particularly for single, first-time mothers
• Housing instability or no fixed home
• History of domestic violence
• Adolescent mother
• Barriers to adequate follow-up care (lack of transportation, no telephone access, non-English-speaking parents)

If any of these risk factors are present and unresolved, delay discharge or implement a safeguarding plan involving social services or child protective services. 4

Safety Education and Anticipatory Guidance

Sleep Safety (Critical Pitfall Area)

• Reinforce supine positioning for sleep and avoidance of co-sleeping—these remain leading causes of preventable infant death. 4, 1, 2
• Educate on firm sleep surface without soft bedding 2

Car Safety

• Verify appropriate car safety seat use—rear-facing until age 2 or until height/weight limit is reached 4, 1, 2
• Car seats should be used only for travel, not for positioning in the home, as prolonged use increases positional asphyxia risk. 4

Illness Recognition

• Instruct parents on recognizing signs of illness, particularly worsening jaundice 4, 1, 2
• Educate on temperature assessment and thermometer use 4, 1
• Review umbilical cord and skin care 4, 1

Medical Home Establishment and Follow-Up

Continuity of Care

• Verify the plan for ongoing health care maintenance, including method for obtaining emergency services 4, 1, 2
• Ensure parents know how to reach the medical home and have emergency contact information 4, 2
• Schedule the next preventive care visit (typically 2-month well child visit) 2

Timing Considerations

For infants discharged before 48 hours after delivery, this 11-day visit fulfills the AAP recommendation for follow-up within 48 hours of discharge. 4, 1 The specific timing guidelines are:

• Discharge before 24 hours: seen by 72 hours of age 1
• Discharge between 24-47.9 hours: seen by 96 hours of age 1
• Discharge between 48-72 hours: seen by 120 hours of age 1

Common Pitfalls to Avoid

The most common error is failing to directly observe feeding rather than relying on parental report alone—inadequate feeding is the leading cause of early readmission and can be missed without direct observation. 4, 1, 2

Another critical pitfall is inadequate maternal depression screening—postpartum depression affects 10-15% of mothers and directly impacts infant care quality, yet screening rates remain suboptimal. 1, 2

Failure to verify newborn screening results is a systems error that can delay diagnosis of treatable metabolic conditions—always confirm results are available and reviewed. 4, 1, 2