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Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
Newborn Care: Skills workshop Clinical history and examination
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Newborn Care: Skills workshop Clinical history and examination

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Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine …

Newborn Care was written for healthcare workers providing special care for newborn infants in level 2 hospitals. It covers: resuscitation at birth, assessing infant size and gestational age, routine care and feeding of both normal and high-risk infants, the prevention, diagnosis and management of hypothermia, hypoglycaemia, jaundice, respiratory distress, infection, trauma, bleeding and congenital abnormalities, communication with parents

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  • 1. Skills workshop: Clinical history and examination infant record. Discussion with the staff who Objectives have cared for the mother and infant is also important. The history will often identify clinical problems and suggest what clinical When you have completed this skills signs to look for during the examination. workshop you should be able to: A general examination is not complete if a • Take a perinatal history. history is not taken. • Perform a physical examination on a newborn infant. 3-b The sections of a perinatal history • Complete an examination chart. 1. The maternal background: • Issue a preschool health card. • The mother’s age, gravidity and parity. • The number of infants that are aliveThe complete examination of a newborn infant and the number that are dead. Theconsists of: cause of death and age at death. • The birth weight of the previous1. The perinatal history infants.2. The physical examination • Any problems with previous infants,3. The assessment of the findings e.g. neonatal jaundice, preterm delivery, congenital abnormalities.TAKING A PERINATAL • The home and socioeconomic status. • Family history of congenitalHISTORY abnormalities. 2. The present pregnancy:3-a The importance of a perinatal history • Gestational age based on menstrualBefore examining a newborn infant, it is dates, early obstetric examination andimportant to first take a careful perinatal ultrasound examination.history. The history should be taken from • Problems during the pregnancy,the mother, together with the maternal and e.g. vaginal bleeding.
  • 2. SK ILLS WORKSHOP : CLINICAL HISTOR Y AND EXAMINATION 73 • Illnesses during the pregnancy, THE PHYSICAL e.g. rubella. • Smoking, alcohol or medicines taken. EXAMINATION OF A • VDRL (or RPR) and TPHA (or FTA) NEWBORN INFANT results. Treatment if syphilis diagnosed. • HIV status and CD4 count if HIV positive. 3-d Requirements for the examination • Antiretroviral prophylaxis or treatment. • Blood groups. 1. Whenever possible the infant’s mother • Assessment of fetal growth and should be present. This gives her the chance condition. to ask questions. She can also be reassured by the examination. The examiner should3. Labour and delivery: use the opportunity to teach the mother • Spontaneous or induced onset of about caring for her infant. labour. 2. A warm environment is essential to • Duration of labour. prevent the infant becoming cold. The • Method of delivery. room should be warm or a source of heat • Signs of fetal distress. must be used, e.g. an overhead radiant • Problems during labour and delivery. heater. Prevent draughts of cold air by • Medicines given to the mother, e.g. closing doors and windows. Do not place pethidine, antiretroviral therapy. the infant on a cold table top. Use a towel or blanket if necessary.4. Infant at delivery: 3. A good light is important so that the • Apgar score and any resuscitation examiner can see the infant well. needed. 4. Wash your hands before examining the • Any abnormalities detected. infant to prevent the spread of infection. • Birth weight and head circumference. 5. The infant should be completely undressed. • Estimated gestational age. A full examination is impossible with the • Vitamin K given. infant partially dressed. • Placental weight. A basic general examination should be5. Infant since delivery: done on all infants. A more detailed general examination is needed in ill infants. • Time since delivery. • Feeds given. 3-e The order of examination • Urine and meconium passed. • Any clinical problems, e.g. hypothermia, The physical examination should always be respiratory distress, hypoglycaemia. performed in a fixed order so that nothing • Contact between infant and mother. is forgotten. Usually the following steps are followed:3-c Assessment of history 1. Measurements:It is a valuable exercise to make an assessmentof the potential and actual problems after • The infant’s weight and head circumferencetaking the history and before examining the are measured and recorded.infant. This helps you to look for important • An assessment of the infant’s gestationalclinical signs that may confirm or exclude age should be made. If necessary,problems suggested by the history. the weight and head circumference measurements can now be plotted against the gestational age on weight and head circumference for gestational age charts.
  • 3. 74 NEWBORN CARE• Often the infant’s skin or axillary on a completed examination form as it will be temperature is measured at this stage of the recorded to the right of the solid line. examination.2. General inspection: 3-g Assessment of the complete examinationA general inspection is made of the infant,paying special attention to the infant’s When the history has been taken and theappearance, nutritional state and skin colour. physical examination completed, an overall assessment of the infant must be made. The3. Regional examination: examiner must decide whether the infant is normal or abnormal. In addition, a list of theThe infant is examined in regions starting problems identified must be drawn up. Theat the head and ending with the feet. The management of each problem can then beexamination of the hips is usually left until last addressed in turn. A perinatal history andas this often makes the infant cry. physical examination are of little value if an assessment is not made.4. Neurological status.5. Examination of the hips. Figure 3.A: On the next page, see a form used to record the results of the physical examination. It can6. Examination of the placenta (if available). also be used as a guideline for a basic general examination.7. An assessment:An assessment is made using all theinformation from the history and the physicalexamination.The physical examination of the newborninfant is not easy and requires a lot of practice.The correct method of examination shouldbe taught at the bedside by an experienceddoctor or nurse. It is not possible to learn howto examine an infant simply by reading anexplanation of the method of examination.3-f Recording the findings of the physicalexaminationUsually a form is used to remind the nurseor doctor which clinical signs to look forand also to record the results of the physicalexamination. The important observationsneeded are listed together with the possiblenormal and abnormal results. The normalresults are given on the left hand side of theform while the abnormal results are given onthe right hand side. The normal and abnormalresults are separated by a bold vertical line. Atick should be placed in the appropriate blocksto indicate which physical signs are present.At a glance any abnormality will be noticed
  • 4. SK ILLS WORKSHOP : CLINICAL HISTOR Y AND EXAMINATION 75General Well SickAppearance Well nourished Obese Wasted DysmorphicBehaviour Responsive Lethargic Irritable JitteryColour Pink Pale Plethoric CyanosedSkin Normal Rash Jaundice Purpura BruisesOdour Normal OffensiveHead shape Normal Asymmetrical Caput Cephal- haematomaFontanelles Normal Bulging LargeSutures Mobile Overriding FusedFace Symmetrical Asymmetrical AbnormalEyes Normal Small Large Slanting DischargeNose Patent BlockedMouth Normal Smooth philtrum Cleft lipPalate Normal CleftTongue Normal Large ProtrudingChin Normal RecedingEars Normal Abnormal Low slungNeck Normal Swellings WebbedClavicles Intact Swellings CrepitusNipples Normal AccessoryRespiratory rate 40 – 60/minute Fast SlowChest movements Symmetrical Asymmetrical ShallowRecession Absent Costal SternalBreath sounds Quiet Grunting NoisyHeart rate 120 – 160/minute Tachycardia BradycardiaPulses Present No femoralArms Normal Not moving FracturePalmar creases Normal Single creaseFingers Normal Polydactyly Syndactyly Extra fingersAbdomen Normal Distended ScaphoidUmbilicus Normal Moist Flare Bleeding Meconium stainedHips Normal Dislocated DislocatableLegs Normal Not movingFeet position Normal Positional Clubbed deformityToes Normal Polydactyly SyndactylyBack Normal Scoliosis Meningocoele Sacral dimple Tuft of hairGenitalia male Testes descended Undescended Fluid hernia Inguinal hernia HypospadiasGenitalia female Normal AmbiguousAnus Patent ImperforateMoro reflex Present and equal Asymmetrical AbsentSucking reflex Present Weak AbsentGrasp reflex Present Weak AbsentMuscle tone Normal Hypotonic HypertonicCry Normal High pitched HoarseAssessment: Examined by:Date and time:
  • 5. 76 NEWBORN CARE3-h Guidelines for a detailed examinationMeasurements Normal AbnormalBirthweight 2500 g to 4000 g. Between 10th Low birthweight (below 2500 g). and 90th centile for gestational Underweight (below 10th centile) age. or overweight (above 90th centile) for gestational age.Head circumference Between 10th and 90th centile Small head (below 10th centile) or for gestational age. large head (above 90th centile for gestational age).Gestational age Physical and neurological Immature features in preterm features of term infants (37– infant (below 37 weeks). Postterm 42 weeks). infants (42 weeks and above) have long nails.Skin temperature Abdominal wall (36–36.5 °C) or Hypothermia (below 36 °C). axilla (36.5–37 °C).GENERAL INSPECTIONWellbeing Active, alert. Lethargic, appears ill.Appearance No abnormalities. Gross abnormalities. Abnormal face.Wasting Well nourished. Soft tissue wasting.Colour Pink tongue. Cyanosis, pallor, jaundice, plethora.Skin Smooth or mildly dry. Vernix Dry, marked peeling. Meconium and lanugo. Stork bite, staining. Petechiae, bruising. mongolian spots, milia, Large or many pigmented erythema toxicum, salmon naevi. Capillary or cavernous patches. haemangioma. Infection. Oedema.Regional examinationHEADShape Caput, moulding. Cephalhaematoma, subaponeurotic bleed. Asymmetry, anencephaly, hydrocephaly, encephalocoele.Fontanelle Open, soft fontanelle with Full or sunken anterior fontanelle. palpable sutures. Large or closed fontanelles. Wide or fused sutures.EYESPosition Wide or closely spaced.Size Small or abnormal eyes.Lids Mild oedema common after Marked oedema, ptosis, bruising. delivery.Conjunctivae May have small subconjunctival Pale or plethoric. Conjunctivitis. haemorrhages. Excessive tearing when nasolacrimal duct obstructed.
  • 6. SK ILLS WORKSHOP : CLINICAL HISTOR Y AND EXAMINATION 77Cornea, iris and lens Cornea clear, regular pupil, red Opaque cornea, irregular pupil, reflex. cataracts, no red reflex, squint, abnormal eye movements.NOSEShape Small and upturned. Flattened in oligohydramnios.Nostrils Both patent. Easy passage of Choanal atresia. Blocked with dry feeding catheter. secretions.Discharge Mucoid, purulent or bloody secretions.MOUTHLips Sucking blisters. Cleft lip. Long smooth upper lip in fetal alcohol syndrome.Palate Epstein’s pearls. High arched or cleft palate.Tongue Pink. Cyanosed, pale, or large.Teeth None at birth. Extra or primary teeth.Gums Small cysts. Tumours.Mucous membranes Pink, shiny. Thrush, ulcers.Saliva Excessive if poor swallowing or oesophageal atresia.Jaw Smaller than in older child. Very small.EARSSite Ears vertical. Low-set ears.Appearance Familial variation. Skin tag or sinus. Malformed ears. Hairy ears.NECKShape Usually short. Webbing, torticollis.Masses No palpable lymph nodes or Cystic hygroma. Goitre. thyroid. Sternomastoid tumour.Clavicle Swelling or fracture.BREASTSAppearance Breast bud at term 5 to 10 mm. Extra or wide spaced nipples. Enlarged, lactating breasts. Mastitis.HEARTPulses Brachial and femoral pulses Pulses weak, collapsing, absent, easily palpable. 120–160 beats fast or slow or irregular. per minute.Capillary filling time Less than 4 seconds over chest Prolonged filling time if infant cold and peripheries. or shocked.Blood pressure Systolic 50 to 70 mm at term. Hypertensive or hypotensive.Precordium Mild pulsation felt over heart Hyperactive precordium. and epigastrium.Apex beat Heard maximally to left of Heard best in right chest in sternum. dextrocardia.
  • 7. 78 NEWBORN CAREMurmurs Soft, short systolic murmur Systolic or diastolic murmurs. common on day 1.Heart failure Oedema, hepatomegaly, tachy- pnoea or excessive weight gain.LUNGSRespiration rate 40-60 breaths per minute. Tachypnoea above 60 breaths Irregular in REM sleep. Periodic per minute. Gasping. Apnoea breathing with no change in with drop in heart rate, pallor or heart rate or colour. cyanosis.Chest shape Symmetrical. Hyperinflated or small chest.Chest movement Symmetrical. Asymmetrical in pneumothorax and diaphragmatic hernia.Recession Mild recession in preterm infant. Severe recession in respiratory distress.Grunting Expiratory grunt in respiratory distress.Stridor Inspiratory stridor a sign of upper airway obstruction.Percussion Resonant bilaterally. Dull with effusion or haemothorax. Hyperresonant with pneumothorax.Air entry Equal air entry over both lungs. Unequal or decreased. Bronchovesicular.Adventitious sounds Transmitted sounds. Crackles, wheeze or rhonchi.ABDOMENUmbilicus 2 arteries and 1 vein. 1 artery, 1 vein. Infection. Bleeding or discharge. Hernia. Exomphalos.Skin Periumbilical redness or oedema.Shape Distended or hollow.Liver Palpable 1 cm below coastal Enlarged, firm, tender. margin, soft.Spleen Not easily felt. Enlarged, firm.Kidneys Often felt but normal size. Enlarged, firm.Masses No other masses palpable. Full Palpable mass. bladder can be percussed.Bowel sounds Heard immediately on Few or absent. auscultation.Anus Patent. Absent or covered.Stools Meconium passed within Blood in stool. White stools in 48 hours of birth. Yellow stools obstructive jaundice. Offensive by day 5. Breastfed stool may be watery stools. green and mucoid.SPINEAppearance Coccygeal dimple or sinus. Sacral dimple or sinus. Scoliosis. Straight spine. Meningomyelocoele.
  • 8. SK ILLS WORKSHOP : CLINICAL HISTOR Y AND EXAMINATION 79GENITALIAPenis Urethral dimple at centre of Hypospadias. glans.Testes Descended by 37 weeks. Undescended.Scrotum Well formed at term. Inguinal hernia. Fluid hernia.Vulva Skin tags, mucoid or bloody Fusion of labia. discharge.Clitoris Uncovered in preterm or wasted Enlarged in adrenal hyperplasia. infants.Urine Passed in first 12 hours. Poor stream suggests posterior urethral valve.ARMSPosition Flexed position in term infant. Brachial palsy.HANDSAppearance Extra, fused or missing fingers. Skin tags. Single palmar crease. Hypoplastic nails.LEGSAppearance Mild bowing of lower legs Dislocatable knees in breach. common.FEETAppearance Positional deformation. Clubbed feet. Abnormal toes.NEUROLOGICAL STATUSBehaviour Alert, responsive. Drowsy, irritable.Position Flexion of all limbs at term. Extended limbs or frog position in preterm and ill infants.Movement Active. Moves all limbs equally Absent, decreased or asymmetrical when awake. Stretches, yawns movement. Jittery or convulsions. and twists.Tone Decreased or increased.Hands Intermittently clenched. Permanently clenched.Cry Good cry when awake. Weak, high pitch or hoarse cry.Vision Follows a face, bright light or Absent or poor following. red object.Hearing Responds to loud noise. No response.Sucking Good suck and rooting reflexes Weak suck at term. after 36 weeks gestation.Moro reflex Full extension then flexion of Absent, incomplete or arms and hands. Symmetrical. asymmetrical response.HIPSMovement Click common. Fully abducted. Dislocated or dislocatable. Limited abduction. NOTE The Moro reflex was described by Ernst Moro in 1918. He was professor of paediatrics in Heidelberg, Germany.
  • 9. 80 NEWBORN CARE3-i Examination of the hips have suffered a chronic intrauterine infection (e.g. syphilis) or fetal hydrops have placentasThe hips must be examined in all newborn that weigh more than expected.infants to exclude congenital dislocation or anunstable hip. There are three layers to the placental membranes. The amnion on the insideThe infant is examined lying supine (back on (prevents the fetus sticking to the membranes),the bed) with the hips flexed to a right angle the chorion in the middle (to provideand knees flexed. strength), and the decidua on the outside.Barlows test demonstrates both a dislocated The amnion is usually smooth and shiny. Ifand a dislocatable (unstable) hip: One hand the healthy amnion is peeled away from theimmobilises the pelvis (thumb over pubic rest of the membranes, it is completely clearramus, fingers over sacrum) while the other and transparent. A cloudy or opaque amnionhand moves the opposite thigh into mid- suggests infection (chorioamnionitis) while aabduction. If the hip is dislocatable, backward granular surface (amnion nodosum) suggestspressure on the inner side of the thigh with too little amniotic fluid (oligohydramnios).the thumb causes the femoral head to slip The membranes should not smell offensive.backwards out of the acetabulum. Conversely The umbilical cord normally has one largeforward pressure on the outer side of the thigh vein and two thick walled arteries. The morewith the fingers would tend to cause the head the pull (e.g. when a cord is relatively shortto spring forwards, back into the acetabulum. due to it being wrapped around the fetal neck)The same procedure is then carried out for the the longer the cord will grow. A short cordopposite side. suggests very poor fetal movement. The cordOrtolani test for a dislocated hip: Both thighs becomes stained green once the amnionticare held so that the examiner’s fingers are fluid has been contaminated with meconiumover the outer side of each thigh (greater for a few hours. A single umbilical artery istrochanter) and his thumbs rest on the inner associated with congenital malformations.side of each thigh (lesser trochanter). Both The umbilical vein has one-way valves (‘false’thighs are then abducted. If a hip is dislocated, knots). A true knot may kill the fetus.a ‘clunk’ can be felt and heard as the femoral The shape of the placenta is not important.head slips forward into its normal position in Most are oval. Usually the umbilical cordthe acetabulum. is inserted into the centre of the placenta with arteries and veins radiating out in3-j Examination of the placenta all directions over the chorionic plate.Every placenta should be carefully examined A peripheral insertion is of no clinicalafter birth as this can provide valuable importance. However, insertion into theinformation about the infant. Usually the membranes in a low-lying placenta can resultgross placental weight is measured and is severe haemorrhage from a fetal vesselrecorded (placenta, membranes and umbilical when the membranes rupture (vasa praevia).cord). As gestation progresses the weight of Arteries always cross over veins. Fetal vesselsthe placenta increases. An infant of 3000 g torn off at the placental edge indicate thatusually has a placenta weighing about 600 g an extra piece of placenta has been retained(between 450 and 750 g). Therefore, at term (accessory lobe). Pale patches on the fetalthe gross placental weight is about a fifth that surface are due to fibrin deposits and are notof the fetus. Infants who are underweight for clinically important.gestational age have both an absolutely and The maternal surface of the placenta is darkrelatively small placenta. In contrast, infants of maroon in preterm infants but becomespoorly controlled diabetics, and infants who grey towards term. A pale placenta suggests
  • 10. SK ILLS WORKSHOP : CLINICAL HISTOR Y AND EXAMINATION 81anaemia. Calcification is not important and developing country. The card is widely usedreflects a good maternal calcium intake. throughout southern Africa.The maternal surface is divided into lobes After delivery each newborn infant is issued(cotyledons). Make sure that the placenta with a road-to-health card which forms theis complete as a retained lobe can result in primary health-care record until the infantpostpartum haemorrhage or infection. Firmly starts school by the age of 6 years. The infant’sattached blood clot, especially if it lies over mother keeps the card in a plastic cover andan area of compressed placenta, suggest should present the card whenever the infantplacental abruption. Fresh infarcts are best is taken to a clinic or hospital. The infant’sidentified on palpation as they form a hard perinatal history, growth, immunisationslump. Old infarcts are yellow or grey and and childhood illnesses are recorded on theeasily seen, especially if the placenta is sliced. card. Usually the infant’s HIV status andIt is of no help to simple describe a placenta management are also recorded on the card.as ‘unhealthy’.It is particularly important to examine the 3-k Completing the road-to-health cardplacentas of twins. Unlike-sexed (boy and girl) after deliverytwins are always non-identical (dizygous).Liked-sex twins are definitely identical After delivery the clinic or hospital staff must(monozygous) if they share a single placenta enter the perinatal details onto the road-to-(monochorionic twins). Monochorionic health card. The details which are usuallyplacentas always have fetal blood vessels on entered onto the card are:the chorioninic place which run from one 1. Maternal information:umbilical cord to the other. Monochorionicplacentas have one chorion and usually two • The mother’s nameamniotic sacs. Two placentas fused together • The mother’s hospital number(dichorionic placentas) may be mistaken for • The mother’s home addressa single placenta. However, there are never 2. Pregnancy and delivery information:fetal blood vessels linking the two umbilical • The duration of pregnancycords. Dichorionic placentas can be seen in • The result of the VDRL or otherboth identical and non-identical twins. The creening test for syphilis and HIVseparating membranes of dichorionic twins • The maternal blood groupalways include both amnion and chorion. • Any pregnancy complicationsPathological examination with histology should • The method of deliverybe requested if an abnormality of the placenta • The date and place of birthis identified. Placental ischaemia, chronic 3. Neonatal data:intrauterine infection and chorioamnionitis areeasily identified on histology. • The Apgar scores • The birth weight (mass), head circumference (and sometimes length)THE ROAD-TO-HEALTH • The name and sex of the infant • The date, infant weight and method ofCARD feeding at dischargeUse of the road-to-health card (preschool Details of the information recorded on thehealth card) is advocated by the World Health preschool health card vary slightly from oneOrganisation as one of the main methods region to another. Sometimes additionalof improving child health, especially in a information is also recorded after delivery.
  • 11. VITAMIN A SUPPLEMENTATION Supplementation: age in months Schedule Date given Signature Road to Health Chart IMPORTANT: always bring this chart when you visit IMMUNISATIONS Date given day month year any health clinic, doctor or hospital and Batch no: Vaccine Site day month year Signature PROPHYLAXIS present the chart on school entry GW 8/123 Department of Health BCG Right arm Mother at delivery boy (not later than 6-8 weeks) 1 x 200 000 IU Childs Polio 0 Oral name girl Infant not breastfed Polio 1 Oral (at 6 weeks) 1 x 50 000 IU Childs ID DTP 1 Left thigh At 6 months* number (up to 11mths) 1 x 100 000 IU Hib 1 Left thigh Date of Place of DTP 1 / Hip 1 Left thigh 12mths 18mths 24mths birth day month year birth (combined) Hep B 1 Right thigh PRIMARY SCHEDULE Birth Birth Birth head weight length circumference Polio 2 Oral At 12 - 60 months 1 x 200 000 IU 30mths 36mths 42mths DTP 2 Left thigh (mark with X) every 6 months Problems during pregnancy / birth / neonatally Hib 2 Left thigh DTP 2 / Hip 2 48mths 54mths 60mths (combined) Left thigh APGAR 1 min. Gestational : age (wks) Mothers : Serology Hep B 2 Right thigh 5 min. Polio 3 Oral TREATMENT OF : Antenatal: Mothers (NOT if prophylactic dose was given within previous month) file numbers : DTP 3 Left thigh Dosage according to following age group: 2-5mths: 50 000IU Delivery: Hib 3 Left thigh (See IMCI classification) 6-11mths: 100 000IU DTP 3 / Hip 3 12-60mths: 200 000IU RtHC information given by: (combined) Left thigh Persistent diarrhoea/ Mothers name: Hep B 3 Right thigh Diarrhoea with Immediate 1 x ............IU severe dehydration Fathers name: Measles 1 Right thigh Immediate 1 x ............IU Who does the child live with? Polio 4 Oral Measles DTP 4 Left arm BOOSTERS 24h repeat 1 x ............IU How many children has the mother had? Immediate 1 x ............IU Date Measles 2 Right arm Xerophthalmia Number Number information 24h repeat 1 x ............IU born alive now given: dd mm yy Polio 5 Oral Reason(s) for death(s): DT 1 Left arm Severe Immediate 1 x ............IU malnutrition In need of special care (mark with X) * Allow a period of at least one month between doses Was the baby less yes no Are any brothers or yes no Visual screening than 2,5kg at birth sisters underweight? A PASSPORT FOR HEALTHY CHILDREN Pencil test (>6 weeks) Is the baby a twin? yes no Is the baby bottle fed? yes no Show mothers you value the use of the Road to Health Chart Date and they will take care of it Result: L: yes no R: yes no tested: dd mm yy Does the mother need Household TB contact? yes no more family support? yes no Snellen Chart test: conduct with E-chart (5> years) Date Are there any reasons yes (for example: no single parent etc.) Result: L: / R: / tested: dd mm yy for taking extra care? Hearing screening Does baby appear to listen when someone is talking or singing? (at 3 months) yes no Date Result: tested: dd mm yy Address of clinic(s) visited Does baby turn to a loud noise? (at 6 months) Date Clinic 1: Clinic 2: Result: L: yes no R: yes no tested: dd mm yy Voice test: Hearing impairment (>12 months) Normal Moderate Severe Date Result: hearing impairment impairment tested: dd mm yy 19 kg Childs Date for next visit name: 18,5 nr. day month year 18 18 centile 4 97th 1 17,5 BCG IMMUNISATIONS 17,5 DTP 17,5 2 17 17 17 0 1 2 3 4 3 16,5 Polio 16,5 Polio 16,5 4 16 16 16 1 2 3 1 2 5 15,5 Hib, DTP & Hep B Measles 15,5 Measles 15,5 6 15 15kg 15kg birth 6wks 10wks 14wks 9mths 18mths tile 7 14,5 14,5 14,5 50th cen 8 14 14 14 Discuss: 9 13,5 13,5 13,5 Breastfeeding 10 13 Child spacing 13 13 Food intake 11 12,5 Oral rehydration solution 12,5 12,5 12 12 12 12 13 11,5 11,5 11,5 14 11 11 11 3rd centile 15 10,5 10,5 10,5 16 10kg 10kg 10kg 17 9,5 9,5 9,5 18 9 9 9 19 8,5 th centile 60% of 50 8,5 8,5 20 8 8 8 21 7,5 7,5 7,5 22 7 I can talk 7 7 23 6,5 6,5 6,5 24 6 6 6 5,5 5,5 5,5 Write on the chart - Any illness e.g. 5kg 5kg 5kg ~ diarrhoea, ~ ARI, etc. 4,5 4,5 4,5 - Admission to hospital, 2 years - Solids introduced, - Breastfeeding stopped, 4 4 - Birth of next child, etc. 24 25 26 27 28 29 30 31 32 33 34 35 3,5 3,5 1 age in months year like this: 3 3 Diarrhoea Extra meals 12 13 14 15 16 17 18 19 20 21 22 23 2,5kg 2,5kg age in months given 2 ARI Birth 1 2 3 4 5 6 7 8 9 10 11 Worm medicine weight age in months 1,5 write 2 to 3 Years Admitted to hospital birth month (2-7 September) 1 Watch the direction of the curve showing the childs growth 0,5 write birth month 1 to 2 Years GOOD VERY DANGEROUS 0 Means the child is Child may be ill, growing well. DANGER SIGN needs extra care. write birth month and year Birth to 1 Year Growth Monitoring Chart Not gaining weight. Find out why. Chart revised: August 2003 jjbFigure 3.B: The front and back of a road-to-health card

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