What should be assessed and managed at a 20‑day‑old infant's well‑child visit?

20-Day-Old Well-Child Visit Assessment

At the 20-day well-child visit, focus on feeding adequacy, weight gain trajectory, jaundice assessment, maternal mental health screening, and verification of newborn screening results, as this visit bridges the critical early neonatal period when many problems first emerge. 1

Growth and Vital Signs Assessment

• Measure weight, length, and head circumference and plot on appropriate growth charts, comparing to birth weight to assess adequacy of weight gain 2, 1
• Weight loss >7-10% from birth weight or failure to regain birth weight by 2 weeks is concerning and requires intervention 2
• Measure vital signs: axillary temperature 36.5-37.4°C, respiratory rate <60 breaths/min, heart rate 100-190 bpm when awake (as low as 70 bpm during quiet sleep) 1
• Assess hydration status by examining skin turgor, mucous membranes, fontanelle fullness, and activity level 2

Feeding Evaluation

Direct observation of feeding is essential—do not rely solely on parental report, as this commonly misses feeding difficulties. 1

• For breastfed infants: directly observe position, latch, swallowing, and satiety during the visit 1
• Confirm frequency of 8-12 feeds per 24 hours 2, 1
• For bottle-fed infants: confirm coordinated sucking, swallowing, and breathing 1
• Document adequate stool and urine patterns (should have at least 6 wet diapers and 3-4 stools per day by this age) 2, 1
• Refer for lactation support if feeding evaluation is not reassuring 1

Jaundice Assessment

• Visually inspect for jaundice and obtain serum bilirubin if clinically indicated 2, 1
• Consider major risk factors: jaundice in first 24 hours of life, blood group incompatibility, gestational age 35-36 weeks, previous sibling requiring phototherapy, exclusive breastfeeding with poor intake, and East Asian race 1
• Educate parents on recognizing signs of worsening jaundice 1

Laboratory and Screening Review

• Review newborn metabolic screening results if not previously done, ensuring timely identification of potential health issues 3, 1
• Review maternal infectious disease screening results (syphilis, hepatitis B surface antigen, HIV status) 1
• Verify completion of hearing screening 1
• Review blood type and direct Coombs test results if clinically indicated (particularly with ABO or Rh incompatibility) 1

Physical Examination

• Perform head-to-toe examination including assessment of umbilical cord healing, skin condition, and genital health 1
• Hip examination: perform Ortolani and Barlow maneuvers to detect developmental dysplasia of the hip, which is more common in females (4-8 times), firstborns, large infants, breech presentation, and those with family history 4
• Red reflex testing to detect abnormalities of the ocular media 3
• External inspection of ocular and periocular structures, pupillary examination, and assessment of fixation and following behavior 3
• Poor eye contact after 8 weeks warrants further assessment 3

Developmental and Motor Assessment

• Assess motor development: infant should demonstrate ability to lift head briefly when prone and show motor symmetry 4, 3
• Evaluate social interaction including eye contact and social smiling (emerging around 6-8 weeks) 3
• Developmental surveillance should occur at every visit to identify potential delays 3

Maternal and Family Assessment

Screen for maternal postpartum depression using a validated screening tool—this is frequently missed and critically important. 2, 1

• Assess quality of mother-infant attachment and infant behavior 2, 1
• Screen for social risk factors requiring intervention: untreated parental substance use, history of child abuse or neglect, parental mental illness, lack of social support, housing instability, and domestic violence history 2, 1
• Assess maternal Tdap vaccination status and provide vaccine if not previously received 1

Safety Education and Anticipatory Guidance

• Reinforce safe sleep practices: back to sleep on firm surface, no co-sleeping, no soft bedding 2, 1
• Educate on proper skin-to-skin care with monitoring to prevent sudden unexpected postnatal collapse 1
• Verify appropriate use of rear-facing car safety seat 2, 1
• Provide education on recognizing signs of illness, particularly worsening jaundice 1
• Discuss temperature assessment and thermometer use 1
• Review umbilical cord care and skin care 1

Follow-Up Planning

• Schedule 2-month well-child visit (typically at 8 weeks of age) 2
• Verify establishment of medical home for ongoing care 2, 1
• Provide emergency contact information and instructions for obtaining emergency services 2, 1

Common Pitfalls to Avoid

• Failing to directly observe breastfeeding when there are concerns about weight gain or feeding adequacy—parental report alone is insufficient 1
• Missing jaundice assessment or failing to obtain bilirubin level when clinically indicated 2
• Not screening for maternal postpartum depression 2
• Overlooking social risk factors that may compromise infant safety 2
• Not ensuring newborn screening results have been reviewed and acted upon if abnormal 2
• Relying solely on parental report of feeding without direct observation 1