WEBVTT 00:00.000 --> 00:01.033 [...] 00:01.033 --> 00:06.999 [Music] 00:07.000 --> 00:09.766 [Narrator:] McMaster University, Mohawk College. 00:09.766 --> 00:12.299 The Ontario Medical Association, 00:12.300 --> 00:15.300 and the Ontario College of Family Physicians. 00:15.300 --> 00:18.166 In cooperation with CHCH TV 00:18.166 --> 00:19.032 presents 00:19.033 --> 00:21.066 Health Care Today. 00:21.066 --> 00:23.266 [Music continues] 00:23.266 --> 00:25.832 [Well Baby Visit] 00:25.833 --> 00:29.899 [Music continues] 00:29.900 --> 00:31.500 Here is Dr. Ray Mailloux 00:31.500 --> 00:32.833 a family physician 00:32.833 --> 00:35.566 and the coordinator of the programmed series 00:35.566 --> 00:37.599 dealing with pre-adolescence. 00:37.600 --> 00:38.733 [...] 00:38.733 --> 00:40.133 [Dr. Ray Mailloux:] Good evening. 00:40.133 --> 00:43.333 This is the first of four more programs 00:43.333 --> 00:46.066 in the Health Care Today series. 00:46.066 --> 00:47.632 With me on the panel tonight are 00:47.633 --> 00:49.066 Dr. Gary Gibson, 00:49.066 --> 00:50.766 and Dr. Glenn Gibson. 00:50.766 --> 00:55.366 We're all members of the same group practice in the nearby area. 00:55.366 --> 00:59.866 The, uh, following programs are going to consist of, uh, 00:59.866 --> 01:01.999 a program on urinary tract infections. 01:02.000 --> 01:03.633 One on respiratory infections, 01:03.633 --> 01:06.766 and the fourth one will be dealing with the 01:06.766 --> 01:09.899 problems surrounding chronic illnesses in children. 01:09.900 --> 01:13.433 The topic this evening is, uh, 01:13.433 --> 01:15.733 that of a well baby visit 01:15.733 --> 01:17.399 in particular 01:17.400 --> 01:19.966 and well child care in general. 01:19.966 --> 01:23.666 And we will be watching a film of a well baby exam, 01:23.666 --> 01:27.666 which we… we’d like you to look at both the good points 01:27.666 --> 01:28.632 and the bad points 01:28.633 --> 01:33.033 of this episode of care, and we'll be discussing it later. 01:33.033 --> 01:37.866 [Baby crying] 01:37.866 --> 01:39.166 [Karen Wilson:] Okay, there we are. 01:39.166 --> 01:40.266 [...] 01:40.266 --> 01:41.899 He seems to be doing very well. 01:41.900 --> 01:44.633 He's gained sixteen ounces since he was here for his last visit. 01:44.633 --> 01:47.199 [Mrs. Pat Miller:] Yes, he’s been eating really well. 01:47.200 --> 01:48.800 But Karen, I’m wondering about meats. 01:48.800 --> 01:51.033 All my friends’ babies have started them by now, [Baby continues to cry] 01:51.033 --> 01:54.766 and it says on the schedule that he’s not to be introduced to them yet. 01:54.766 --> 01:55.599 What should I do? 01:55.600 --> 01:59.266 [Karen Wilson:] Well, Dr. Gibson does like to introduce things systematically, 01:59.266 --> 02:01.766 so it’s probably best if you just follow the instruction sheet. 02:01.766 --> 02:02.299 [Mrs. Pat Miller:] Yeah. 02:02.300 --> 02:03.600 [Karen Wilson:] Okay. 02:03.600 --> 02:06.166 [...] 02:06.166 --> 02:07.366 [Dr. Gary Gibson:] Morning, [?] 02:07.366 --> 02:08.532 [Mrs. Pat Miller:] Hi. 02:08.533 --> 02:09.599 [Dr. Gary Gibson:] Where is Shane? 02:09.600 --> 02:11.600 All right. 02:11.600 --> 02:13.600 Any problems so far that you’re having Pat? 02:13.600 --> 02:14.500 [Mrs. Pat Miller:] Absolutely no, no. 02:14.500 --> 02:15.500 [Dr. Gary Gibson:] Sounds good. 02:15.500 --> 02:15.800 [...] 02:15.800 --> 02:17.800 Well, we’ll have a little look at things this morning 02:17.800 --> 02:19.600 and see how things are going here. 02:19.600 --> 02:21.333 You got the measurements down here Karen? 02:21.333 --> 02:22.433 Okay. 02:22.433 --> 02:24.299 [...] 02:24.300 --> 02:27.333 Okay, sir, well let’s just [?] it first here. 02:27.333 --> 02:32.133 [...] 02:32.133 --> 02:34.833 Heart sounds are normal, Karen. 02:34.833 --> 02:40.999 [...] 02:41.000 --> 02:45.666 Hmm, that’s good. Lungs are clear, no problems there. 02:45.666 --> 02:51.566 [...] 02:51.566 --> 02:55.399 Okay. 02:55.400 --> 03:01.233 Fontanel is about two centimeters. 03:01.233 --> 03:02.199 [Baby making cooing sounds] 03:02.200 --> 03:03.433 [Dr. Gary Gibson:] No nodes in the neck. 03:03.433 --> 03:08.799 Shall I have a look in your ears? 03:08.800 --> 03:11.766 See if I [?] Shane. 03:11.766 --> 03:14.966 We’ll have a peek. 03:14.966 --> 03:16.632 There we go. 03:16.633 --> 03:19.966 [...] 03:19.966 --> 03:21.966 Right is clear. 03:21.966 --> 03:24.099 [...] 03:24.100 --> 03:27.466 And the left is clear. 03:27.466 --> 03:29.099 Got any teeth yet? 03:29.100 --> 03:34.200 Probably not. 03:34.200 --> 03:38.233 We’ll take a look around. 03:38.233 --> 03:39.699 No teeth. 03:39.700 --> 03:40.933 Throat’s clear. 03:40.933 --> 03:43.399 Palate’s intact. 03:43.400 --> 03:45.533 [Exam instrument clanking] 03:45.533 --> 03:48.866 Shall we try to have a look at your eyes, too, for a jiffy? 03:48.866 --> 03:56.232 [...] 03:56.233 --> 03:59.666 Mostly clear on the right. 03:59.666 --> 04:03.032 And the same on the left. 04:03.033 --> 04:07.399 [...] 04:07.400 --> 04:09.133 And the abdomen… 04:09.133 --> 04:10.433 [Baby giggles] 04:10.433 --> 04:15.566 You’re ticklish already! 04:15.566 --> 04:16.766 [?] is not palpable [?] 04:16.766 --> 04:22.266 [?] his chest, [?] down [?] here. 04:22.266 --> 04:23.299 Good. 04:23.300 --> 04:24.866 [...] 04:24.866 --> 04:29.099 And femoral pulse is [?] 04:29.100 --> 04:32.366 Okay, we’ll check a few reflexes here, too, Shane. 04:32.366 --> 04:39.099 [...] 04:39.100 --> 04:44.500 Biceps and triceps equal about two plus two. 04:44.500 --> 04:47.300 Now okay. 04:47.300 --> 04:49.466 These three plus. 04:49.466 --> 04:52.366 [...] 04:52.366 --> 04:56.599 Ankles, three pluss...still good. 04:56.600 --> 04:59.833 Let’s see what you… Tickle. Foot. 04:59.833 --> 05:04.833 [...] 05:04.833 --> 05:09.633 Toes appear to be down...and [?]. 05:09.633 --> 05:13.533 And glabella, positive... 05:13.533 --> 05:17.066 [...] 05:17.066 --> 05:23.899 Let’s check the testicles. Testicles are both down. [?] is palpable. 05:23.900 --> 05:27.333 And hips, normal. 05:27.333 --> 05:30.099 Okay, everything seems very good, Pat. 05:30.100 --> 05:34.100 Really, there’s no…no problems. Um, this is the third shot today. 05:34.100 --> 05:36.166 Karen will administer it in just a minute. 05:36.166 --> 05:40.366 And we really don't need to see him again now until he’s a year. 05:40.366 --> 05:41.566 That's when the next shot's due. 05:41.566 --> 05:42.532 [Mrs. Pat Miller:] Okay. 05:42.533 --> 05:44.399 [Dr. Gary Gibson:] So we'll see then. 05:44.400 --> 05:46.500 Bye for now, Shane. 05:46.500 --> 05:48.233 [Dr. Glenn Gibson:] 05:48.233 --> 05:50.599 Well, that's certainly seemed to be a very thorough examination. 05:50.600 --> 05:53.966 Um, there were a couple things I'd kind of wonder about, though. 05:53.966 --> 05:56.732 [Dr. Ray Mailloux:] One of the things that I’d noticed was that the 05:56.733 --> 05:59.933 baby was weighed with his diapers on. 05:59.933 --> 06:04.699 Which seems to make it hard to get consistent weighing from one visit to another. 06:04.700 --> 06:06.966 I've always felt that you should have them 06:06.966 --> 06:08.799 naked when they're… when they’re weighed. 06:08.800 --> 06:11.233 The other thing I was noticing was that mother was… 06:11.233 --> 06:15.133 seemed to be having some problems with her feeding schedule for the baby. 06:15.133 --> 06:17.233 [Dr. Gary Gibson:] We thought we'd probably looked after that adequately Ray, 06:17.233 --> 06:19.333 there’s the, uh, as Karen mentioned to her, 06:19.333 --> 06:23.233 we had given her instruction sheets, which are actually pretty detailed. 06:23.233 --> 06:25.533 Step by step, and uh, you know, in our practice, 06:25.533 --> 06:30.199 we’d found it saves a fair bit of time to have them already have it written down. 06:30.200 --> 06:32.933 [Dr. Glenn Gibson:] Well, if you're gonna be that rigid with your feeding, 06:32.933 --> 06:37.433 I think you need some sort of instruction sheets to try and keep mother straight. 06:37.433 --> 06:39.299 [Dr. Ray Mailloux:] You don't like that idea then? 06:39.300 --> 06:41.166 [Dr. Glenn Gibson:] No, I really don't go along with uh… 06:41.166 --> 06:42.466 with that sort of approach. 06:42.466 --> 06:44.632 [Dr. Ray Mailloux:] Well, let's see how you handle the uh… 06:44.633 --> 06:46.066 that baby visit. 06:46.066 --> 06:51.366 [...] 06:51.366 --> 06:54.799 [Baby cooing] 06:54.800 --> 06:57.400 [Baby fussing] 06:57.400 --> 06:59.533 [Karen Wilson:] He seems to be coming along very well Pat. 06:59.533 --> 07:02.866 He’s gained sixteen ounces since he was here for his last visit. 07:02.866 --> 07:05.232 [Mrs. Pat Miller:] Yes, he’s been eating really well. Um, 07:05.233 --> 07:07.866 Karen, do you think that it’s time that I started him on the meats? 07:07.866 --> 07:10.566 [Karen Wilson:] Well, I’ll tell you, why don’t you wait till Dr. Gibson comes in 07:10.566 --> 07:12.032 and you can discuss it with [?]. 07:12.033 --> 07:17.199 [Baby cooing] 07:17.200 --> 07:18.300 [Dr. Glenn Gibson:] Hi there, sorry I'm late. 07:18.300 --> 07:19.066 [Mrs. Pat Miller:] Oh, that’s okay. 07:19.066 --> 07:20.132 [Dr. Glenn Gibson:] How’s everything going? 07:20.133 --> 07:21.733 [Karen Wilson:] Oh, he seems to be coming along really well. 07:21.733 --> 07:23.733 He’s gaining about a half an ounce a day. 07:23.733 --> 07:26.833 But mom does want to ask a few questions about his feeding. 07:26.833 --> 07:28.533 [Dr. Glenn Gibson:] What sort of things, Pat? 07:28.533 --> 07:31.199 [Mrs. Pat Miller:] Oh, everything’s fine, but do you think I could start him on meat? 07:31.200 --> 07:33.233 [Dr. Glenn Gibson:] Meat? What all have you got him on so far? 07:33.233 --> 07:35.333 [Mrs. Pat Miller:] Well, he’s still on formula, of course, 07:35.333 --> 07:37.333 and I give him Pablum every day, 07:37.333 --> 07:39.266 and I’ve started him on fruit. 07:39.266 --> 07:40.332 [Dr. Glenn Gibson:] How about vegetables? 07:40.333 --> 07:43.966 [Mrs. Pat Miller:] Well, I’ve tried to give him vegetables, but he doesn’t really like them. 07:43.966 --> 07:47.266 [Dr. Glenn Gibson:] Okay. Well, why don't you try him on some meat now, 07:47.266 --> 07:50.099 and then maybe we can try the vegetables again later on. 07:50.100 --> 07:52.000 [...] 07:52.000 --> 07:53.000 [Dr. Glenn Gibson:] That's my approach. 07:53.000 --> 07:56.600 I really don't think you should be rigid about the feeding schedules at all. 07:56.600 --> 07:59.366 [Dr. Gary Gibson:] I see, you’re not using handouts then at all really 07:59.366 --> 08:01.999 for feeding instructions for mother. 08:02.000 --> 08:05.166 [Dr. Glenn Gibson:] No, I think if you're too structured with it, 08:05.166 --> 08:08.366 that really all that leads to is anxiety in the mother. 08:08.366 --> 08:11.132 She gets upset because her baby doesn't quite fit the schedules. 08:11.133 --> 08:14.966 And it really is more problems than it's worth. 08:14.966 --> 08:19.732 [Dr. Ray Mailloux:] Well, shall we see where you go from there, then? 08:19.733 --> 08:21.166 [Dr. Glenn Gibson:] Any other troubles? 08:21.166 --> 08:22.766 [Mrs. Pat Miller:] No, everything’s quite fine. 08:22.766 --> 08:24.399 [Dr. Glenn Gibson:] How about his bowels? 08:24.400 --> 08:25.433 [Mrs. Pat Miller:] Oh, they’re very regular. 08:25.433 --> 08:26.566 [Dr. Glenn Gibson:] Good. 08:26.566 --> 08:28.032 And sleeping? 08:28.033 --> 08:29.533 [Mrs. Pat Miller:] Oh, he’s very good. 08:29.533 --> 08:31.066 [Dr. Glenn Gibson:] Is he up at all at night? 08:31.066 --> 08:33.732 [Mrs. Pat Miller:] Yes, he is. Um, 08:33.733 --> 08:37.299 I put him bed at 8 but he gets up three and four times after midnight. 08:37.300 --> 08:40.566 [Dr. Gary Gibson:] Well, that's odd, then. 08:40.566 --> 08:42.032 Then she didn't tell me about the… 08:42.033 --> 08:44.333 that sleep problem when she was talking to me. 08:44.333 --> 08:46.899 [Dr. Ray Mailloux:] Well, she didn't really tell Glenn about it either, 08:46.900 --> 08:49.600 but he asked rather more specific questions. 08:49.600 --> 08:53.200 [Dr. Glenn Gibson:] I think a lot of mothers are really afraid to ask things like that. 08:53.200 --> 08:57.500 And unless you bring up the subject, they just won't tell you about it. 08:57.500 --> 09:03.366 [Dr. Ray Mailloux:] Where, um… Let's see where you go from there, then, Glenn. 09:03.366 --> 09:04.099 [...] 09:04.100 --> 09:05.433 [Dr. Gary Gibson:] The um, 09:05.433 --> 09:07.733 sleep pattern is the thing that, uh, 09:07.733 --> 09:11.166 probably I missed very much in that discussion. 09:11.166 --> 09:14.766 And, uh, well, it probably is an important thing, 09:14.766 --> 09:16.666 because mother’s always gonna get quite tired out 09:16.666 --> 09:19.332 having to get up that often through the night. 09:19.333 --> 09:24.033 I suppose one thing might do is to give the mother, give the mother… I'm sorry, 09:24.033 --> 09:26.799 give the child, a night sedative, maybe mother, too, 09:26.800 --> 09:31.266 but give the child something like phenobarb or [?], something of that sort. 09:31.266 --> 09:33.499 [Dr. Glenn Gibson:] No, I certainly… certainly wouldn't go along with that. 09:33.500 --> 09:37.100 I think, uh, sleep disturbances in the child 09:37.100 --> 09:40.466 very often indicate problems in the family, 09:40.466 --> 09:42.099 not so much with the baby, 09:42.100 --> 09:43.866 but with the family as a whole. 09:43.866 --> 09:47.199 And I think things like that you shouldn't just pass over. 09:47.200 --> 09:52.400 You should go into further and try and find out what's going on with the family. 09:52.400 --> 09:54.466 One other thing with the examination, 09:54.466 --> 09:58.766 you didn't seem to be checking for milestones. 09:58.766 --> 10:01.332 [Dr. Gary Gibson:] Uh, you're referring to something like the Denver grid 10:01.333 --> 10:05.599 then that has a sort of large number of motor development 10:05.600 --> 10:07.433 as well as social functions. 10:07.433 --> 10:09.866 It’s… it's really a very time-consuming thing, 10:09.866 --> 10:13.532 and I normally don’t… don't bother doing anything like that at all. 10:13.533 --> 10:15.366 And you saw the examination that I do, 10:15.366 --> 10:16.899 which is obviously fairly thorough. 10:16.900 --> 10:20.100 But the other, it takes quite a bit of time. 10:20.100 --> 10:23.300 [Dr. Glenn Gibson:] Well, here, let me show you, uh, show you what I mean. 10:23.300 --> 10:26.033 [...] 10:26.033 --> 10:28.033 There we go, that's a good guy. 10:28.033 --> 10:29.399 Here, let's turn you over, Shane. 10:29.400 --> 10:32.100 Can you turn over there? 10:32.100 --> 10:33.766 That's the way. 10:33.766 --> 10:35.466 [Shane cooing] 10:35.466 --> 10:38.432 That’s the way. 10:38.433 --> 10:39.899 Can you see my light? You can see it. 10:39.900 --> 10:44.433 You see my light? You see my light? 10:44.433 --> 10:46.299 You look over here. 10:46.300 --> 10:48.933 [...] 10:48.933 --> 10:50.099 That's the way. 10:50.100 --> 10:51.933 Okay. 10:51.933 --> 10:54.899 Now, let's see, by four months, 10:54.900 --> 11:01.600 he should be… Uh. When did he learn to roll over? 11:01.600 --> 11:05.100 There in really just a few seconds, you've established 11:05.100 --> 11:08.933 that he has in fact met four of his major milestones for four months. 11:08.933 --> 11:12.766 He's holding his head up on his elbows. Uh, 11:12.766 --> 11:15.332 he's turning his head to follow a light. 11:15.333 --> 11:16.666 He's smiling. 11:16.666 --> 11:18.199 And he has learned to roll over. 11:18.200 --> 11:22.400 [Dr. Ray Mailloux:] I guess you would only need to go into a detailed comparison 11:22.400 --> 11:23.600 with the Denver grid 11:23.600 --> 11:25.566 if you thought that there were any problems. 11:25.566 --> 11:26.466 [Dr. Gary Gibson:] I see. 11:26.466 --> 11:27.966 Well it’s… it's certainly a good points. 11:27.966 --> 11:31.266 I did an awful lot of neurological investigation. 11:31.266 --> 11:32.966 It really didn't tell me the milestones, 11:32.966 --> 11:36.332 and I suppose I probably shouldn’t… should use more of that examination time 11:36.333 --> 11:41.199 to check milestones rather than every other reflex I can think of. 11:41.200 --> 11:43.400 [Dr. Glenn Gibson:] I think that would certainly be a worthwhile change 11:43.400 --> 11:46.066 from the routine you showed us. 11:46.066 --> 11:49.299 [Dr. Ray Mailloux:] Glenn, are there any other differences in the way you do things? 11:49.300 --> 11:52.433 [Dr. Glenn Gibson:] I don't think there are any major changes, 11:52.433 --> 11:54.233 not as detailed as Gary's. 11:54.233 --> 11:54.899 But other than that, 11:54.900 --> 11:58.366 basically the same sort of physical examination. 11:58.366 --> 12:01.199 [Dr. Ray Mailloux:] Gary, I noticed that you arranged to see him 12:01.200 --> 12:02.400 when he was a year old, 12:02.400 --> 12:04.633 which is a full eight months away. 12:04.633 --> 12:08.633 Um, let's see what you do with that, Glenn. Okay. 12:08.633 --> 12:09.799 [Dr. Glenn Gibson:] Okay. 12:09.800 --> 12:13.300 [...] 12:13.300 --> 12:14.400 [Dr. Glenn Gibson:] There we go, Shane. 12:14.400 --> 12:16.166 Let’s wiggle you around here. 12:16.166 --> 12:18.432 [Baby crying] That's good. 12:18.433 --> 12:21.566 Okay, well, everything certainly seems to be fine, Pat. 12:21.566 --> 12:24.566 Uh, now, he’s due for his third needle today, 12:24.566 --> 12:26.132 and that’ll be the last one till he’s, uh, 12:26.133 --> 12:27.666 until he’s a year old. 12:27.666 --> 12:30.199 I’d kinda like to see him, though, around eight months or so 12:30.200 --> 12:31.633 just to see how things are doing, 12:31.633 --> 12:33.799 or sooner of course if there’s any troubles. 12:33.800 --> 12:35.766 Any other questions? 12:35.766 --> 12:38.299 [Mrs. Pat Miller:] No, the feeding was the only problem I had. 12:38.300 --> 12:41.500 [Dr. Glenn Gibson:] Good. Okay, well, let's go ahead and give it a shot today 12:41.500 --> 12:42.600 and we're all set then. 12:42.600 --> 12:43.433 [Mrs. Pat Miller:] Okay. 12:43.433 --> 12:45.399 [...] 12:45.400 --> 12:46.900 [Dr. Ray Mailloux:] So you're gonna bring him back when he's eight months, 12:46.900 --> 12:49.833 which is really before he's due for another shot? 12:49.833 --> 12:50.799 [Dr. Glenn Gibson:] I think so. 12:50.800 --> 12:52.566 I get pretty well all of them back at eight months 12:52.566 --> 12:53.966 and sometimes even… even 12:53.966 --> 12:56.832 a couple of times between four months and a year, 12:56.833 --> 12:59.999 if there are any… any problems showing up. 13:00.000 --> 13:03.666 [Dr. Gary Gibson:] So you're… you're really gauging it a bit then… 13:03.666 --> 13:06.399 then on how… how much trouble the mother is having 13:06.400 --> 13:10.900 or if there are any concerns about developmental milestones. 13:10.900 --> 13:13.633 Adjusted fairly flexibly, do you? 13:13.633 --> 13:15.033 [Dr. Glenn Gibson:] Pretty much. 13:15.033 --> 13:16.966 If the child was doing perfectly well 13:16.966 --> 13:19.066 and has been meeting all the milestones and so on, 13:19.066 --> 13:22.932 then you're unlikely to run into problems during that time. 13:22.933 --> 13:26.299 But if there are any indications early on that things aren't going well. 13:26.300 --> 13:30.766 I certainly get those back in to keep checking the milestones 13:30.766 --> 13:34.166 and just see if they are getting further behind or what's happening. 13:34.166 --> 13:36.299 [Dr. Ray Mailloux:] So on a routine, then, you're… 13:36.300 --> 13:38.900 you're asking them to bring the baby in once 13:38.900 --> 13:43.066 between those… the last… the early needles and 13:43.066 --> 13:44.599 the next one due in a year. 13:44.600 --> 13:47.733 [Dr. Glenn Gibson:] Right, that would be my standard routine. 13:47.733 --> 13:49.533 [Dr. Gary Gibson:] This can obviously be, you know, 13:49.533 --> 13:51.066 be fluctuated a fair bit, 13:51.066 --> 13:53.199 depending on what your own immunization schedule is, too. 13:53.200 --> 13:59.266 And there’s all kinds of different systems and probably the exact visit times can be adjusted 13:59.266 --> 14:01.199 to your own pattern, too. 14:01.200 --> 14:04.233 It might end up being at two, four, six months, 14:04.233 --> 14:07.533 and nine, or something like that, I suppose, too. 14:07.533 --> 14:09.033 [Dr. Ray Mailloux:] I think one of the things we're trying to do is… 14:09.033 --> 14:13.599 is to sort of get away from the physical examination 14:13.600 --> 14:15.733 and the giving of shots as a goal 14:15.733 --> 14:17.999 for… for the visit and concentrate on 14:18.000 --> 14:20.533 how well this child is doing in developing. 14:20.533 --> 14:22.599 [...] 14:22.600 --> 14:25.366 [Dr. Gary Gibson:] The place of the Denver grid, 14:25.366 --> 14:28.099 I think we should probably talk about a little bit more. 14:28.100 --> 14:31.466 As we implied in our earlier role-playing parts, 14:31.466 --> 14:37.132 the Denver grid is obviously a fairly complex system. 14:37.133 --> 14:40.633 And there are all kinds of the drug companies in the formula companies 14:40.633 --> 14:44.266 that make them. Some of them shortened up and some not, 14:44.266 --> 14:46.799 but… and generally fairly complicated. 14:46.800 --> 14:49.966 The other part about the Denver… Denver grid 14:49.966 --> 14:52.599 that we haven’t commented on is the… sort of the variation 14:52.600 --> 14:54.933 of the milestones. 14:54.933 --> 14:58.766 Um, how do you handle that part, Ray? 14:58.766 --> 15:04.132 [Dr. Ray Mailloux:] I try to keep in mind some of the major ones such as, 15:04.133 --> 15:08.033 oh, smiling, being able to roll over. 15:08.033 --> 15:11.033 Relating to you when… when you’re… as Glenn did, 15:11.033 --> 15:12.366 when trying to deal with them. 15:12.366 --> 15:16.366 And by the second or the third visit, 15:16.366 --> 15:19.099 well they should certainly be doing those things. 15:19.100 --> 15:20.100 So if they're not, you know, 15:20.100 --> 15:22.800 you're only keeping a few things in line out of the big, 15:22.800 --> 15:24.566 massive things on the grand Denver grid. 15:24.566 --> 15:26.899 And they're the ones that might… 15:26.900 --> 15:29.666 they might begin to smile at six m… six weeks. 15:29.666 --> 15:31.332 But if they're not doing it by three months, 15:31.333 --> 15:34.533 it certainly really strikes you, so those of the ones you keep in mind. 15:34.533 --> 15:36.433 [Dr. Gary Gibson:] Starts getting worrying about then. 15:36.433 --> 15:37.299 [Dr. Glenn Gibson:] And then you’d, what, 15:37.300 --> 15:39.900 go into a more detailed use of the Denver grid if… 15:39.900 --> 15:43.400 if you found something like that, that wasn't doing what he should. 15:43.400 --> 15:45.833 [Dr. Ray Mailloux:] You could bring them back again, set up to get some time to do it, 15:45.833 --> 15:48.466 either that or send them to someone else who can do it. 15:48.466 --> 15:52.832 Get a good assessment of whether they are behind or not. 15:52.833 --> 15:55.566 [Dr. Gary Gibson:] All right. 15:55.566 --> 15:58.599 [Dr. Ray Mailloux:] The same kind of thing that, uh, 15:58.600 --> 16:00.166 say when you bring them in at eight months. 16:00.166 --> 16:03.366 By eight months, you expect the child to be sitting. 16:03.366 --> 16:06.132 Perhaps beginning to pull himself up. 16:06.133 --> 16:10.766 Um, if he's not crawling should be upon his hands and knees. 16:10.766 --> 16:12.999 And sometimes they're not doing that at that particular point in time, 16:13.000 --> 16:15.800 you certainly begin to wonder. 16:15.800 --> 16:17.433 Where if you don't see them for a year, 16:17.433 --> 16:20.099 you've missed four or five… four or five months 16:20.100 --> 16:23.700 and you're in your development scale. 16:23.700 --> 16:25.566 [Dr. Gary Gibson:] I think probably from a practical standpoint, 16:25.566 --> 16:28.999 thinking back to my own training days that I was really not given 16:29.000 --> 16:31.833 any kind of indicator of milestones, 16:31.833 --> 16:34.033 that I was given a great long sheet, 16:34.033 --> 16:35.799 and much like the Denver grid only at that time, 16:35.800 --> 16:39.200 just printed up. Saying this is what the baby 16:39.200 --> 16:41.433 should be doing at two months, three months, four months. 16:41.433 --> 16:43.899 Really a hopeless business to try to remember. 16:43.900 --> 16:47.433 And I remember thinking back in my early days of training 16:47.433 --> 16:50.066 and practice. That it was just impossible 16:50.066 --> 16:51.932 and almost gave up doing it. 16:51.933 --> 16:53.499 [Dr. Ray Mailloux:] It certainly makes a big difference 16:53.500 --> 16:56.466 when you have kids yourself to help you remember them. 16:56.466 --> 17:00.132 [Dr. Glenn Gibson:] The other thing with regard to the actual physical examination, 17:00.133 --> 17:02.599 just how thorough an exam do you think is justified 17:02.600 --> 17:05.533 at each of these well baby visits? 17:05.533 --> 17:07.733 [...] 17:07.733 --> 17:09.999 [Dr. Ray Mailloux:] You do thorough examinations 17:10.000 --> 17:12.400 presumably when the baby is born. 17:12.400 --> 17:14.533 And maybe once or twice more in the office. 17:14.533 --> 17:17.866 But there's so many of the things that once you establish that they’re normal, 17:17.866 --> 17:19.866 they're not really gonna change again. 17:19.866 --> 17:21.966 If you find that femoral pulses are there, well, 17:21.966 --> 17:24.332 you're not going to expect them to disappear. 17:24.333 --> 17:26.233 They don't really need to be checked each time. 17:26.233 --> 17:28.666 Some things do change. 17:28.666 --> 17:32.499 Heart murmurs can develop in the… in the first few months 17:32.500 --> 17:33.666 that weren't there at the beginning. 17:33.666 --> 17:38.899 [Dr. Gary Gibson:] Frequently not there the first… first few weeks, even, right. 17:38.900 --> 17:41.700 [Dr. Glenn Gibson:] What do you do about recording these visits now, 17:41.700 --> 17:43.366 when the kids are in? 17:43.366 --> 17:45.599 Do you write down a full page for every visit 17:45.600 --> 17:48.500 or what’s… What’s your routine? 17:48.500 --> 17:53.666 [Dr. Ray Mailloux:] I… again I sort of keep a number of key things in mind, then. 17:53.666 --> 17:56.099 Things that I check each time. 17:56.100 --> 18:00.633 Such as, oh, the hips for any evidence of congenital hip disease and so on. 18:00.633 --> 18:02.699 I try and record those in such a way that I, 18:02.700 --> 18:03.800 quickly glancing back, 18:03.800 --> 18:05.766 I can see that it was done last time and it was normal, 18:05.766 --> 18:08.466 and if there are any changes then they stand out this time. 18:08.466 --> 18:11.699 I feel strongly that the records are a bit of a problem, you know. 18:11.700 --> 18:15.600 If you're going to do complete examinations when the baby's born in the hospital 18:15.600 --> 18:19.633 and you're gonna assess and record Apgar scores in the hospital. 18:19.633 --> 18:23.466 Um, I find that often, or easily anyway, 18:23.466 --> 18:28.466 they don't get back into the chart for reference back due in a few months. 18:28.466 --> 18:31.599 [Dr. Glenn Gibson:] This is particularly true in a group set-up like ours. 18:31.600 --> 18:35.833 Where there are lots of occasions when the child is being seen 18:35.833 --> 18:37.833 by a different doctor for some reason, 18:37.833 --> 18:40.833 and even if you remember that that was normal on the last visit, 18:40.833 --> 18:43.733 it's not going to do the examining physician much good at that point. 18:43.733 --> 18:48.099 [Dr. Gary Gibson:] It's got to be written down someplace, or it’s… or it’s of no use at all. 18:48.100 --> 18:50.300 For those of us in this practice, 18:50.300 --> 18:53.900 know that we've almost annually have a fight about what kind of records 18:53.900 --> 18:56.100 we're going to use for well baby visits. 18:56.100 --> 19:00.900 You're always in this battle of trying to keep the numbers of pieces of paper down. 19:00.900 --> 19:03.966 There are all kinds of flow sheets available, 19:03.966 --> 19:09.199 which are fine for following milestones and well baby care, 19:09.200 --> 19:11.400 and then you get a sickness episode thrown in. 19:11.400 --> 19:13.200 And that is… Does that go onto another page? 19:13.200 --> 19:19.433 And you keep growth percentile charts, uh, separate on another page as well. 19:19.433 --> 19:21.066 It's really tough. 19:21.066 --> 19:23.266 [Dr. Ray Mailloux:] I personally would still like to see us using a checklist, 19:23.266 --> 19:26.299 at least for the identifiable well baby visits. 19:26.300 --> 19:32.466 [Dr. Glenn Gibson:] This is the reason we have an annual discussion is to try and sort this out. 19:32.466 --> 19:35.266 [Dr. Ray Mailloux:] Glenn, you mentioned then, somewhere along the way, 19:35.266 --> 19:36.732 that you were gonna pursue… 19:36.733 --> 19:42.199 that you’d like to pursue things like the mother’s mentioning of sleep patterns. 19:42.200 --> 19:45.700 Um, what did you mean by that? 19:45.700 --> 19:50.066 [Dr. Glenn Gibson:] Well, I think… I think things like that are often a… as I mentioned 19:50.066 --> 19:52.666 a sign that there are other troubles in the family. 19:52.666 --> 19:54.866 Not so much just with the baby itself. 19:54.866 --> 19:59.566 And I think it, uh, it's worth pursuing those to some extent. 19:59.566 --> 20:03.866 Just to see what is going on in the family. 20:03.866 --> 20:09.832 [Dr. Gary Gibson:] Is… Is sleep the only… only thing that you find, Glenn, that gets disturbed? 20:09.833 --> 20:13.199 [Dr. Glenn Gibson:] Well, no, certainly in this four month age group 20:13.200 --> 20:14.600 that we're talking about tonight 20:14.600 --> 20:17.500 that… that's probably the commonest disturbance is in the sleeping. 20:17.500 --> 20:20.533 But for different age groups, 20:20.533 --> 20:24.566 I think you'll find there are different things that do get, uh... 20:24.566 --> 20:27.466 disturbed when the child is upset about something. 20:27.466 --> 20:30.732 [Dr. Gary Gibson:] It took me a couple of years in the practice to start recognizing 20:30.733 --> 20:32.999 what was happening, but I agree very much. 20:33.000 --> 20:35.200 I think there are almost characteristic functions 20:35.200 --> 20:37.900 that go haywire at, uh, in different age groups 20:37.900 --> 20:42.000 and typically the sleep is the main one at this age. 20:42.000 --> 20:48.600 Maybe even colic may in fact be one of the indicators of… of stress in the family 20:48.600 --> 20:50.066 of one sort or another in this age group. 20:50.066 --> 20:54.632 And then you get on a little bit further, say the one- to two-year-olds, 20:54.633 --> 20:57.299 it's more often that they won't go to sleep at night. 20:57.300 --> 21:01.266 They stay up late and maybe make a great fuss about eating. 21:01.266 --> 21:05.332 And that's also the same kind of a triggering, should trigger us anyway, 21:05.333 --> 21:06.266 to think what's going on? 21:06.266 --> 21:09.699 [Dr. Ray Mailloux:] I think we have to try not to overreact, you know. 21:09.700 --> 21:11.800 If I see a mother who's got three kids at home 21:11.800 --> 21:16.733 and each one of them is headed up five times every night until they were a year of age 21:16.733 --> 21:21.466 um, I tend not to rock the boat too much. And she's already been through it three times, 21:21.466 --> 21:23.399 and that's the way she seems to want it. 21:23.400 --> 21:25.466 [Dr. Ray Mailloux:] And certainly if it’s a young mother, though, 21:25.466 --> 21:29.532 on a young marriage. I'll take a closer look at it. 21:29.533 --> 21:31.666 [Dr. Glenn Gibson:] Sometimes you don't actually have to get into 21:31.666 --> 21:33.666 any great counseling episode. 21:33.666 --> 21:36.132 It's often just, particularly in the young mothers, 21:36.133 --> 21:37.899 that they don't know what is normal. 21:37.900 --> 21:39.200 They don't know what to expect, 21:39.200 --> 21:40.666 and they don't know what to do about it. 21:40.666 --> 21:44.799 And often a few very directive suggestions is all you need to do. 21:44.800 --> 21:47.666 And things will be fine. 21:47.666 --> 21:51.199 [Dr. Gary Gibson:] How do you… How do you decide when you're going to just either 21:51.200 --> 21:54.233 let it pass off as being a temporary problem 21:54.233 --> 21:56.999 or when are you gonna use behavior modification. 21:57.000 --> 21:59.166 Which is maybe just leaving… 21:59.166 --> 22:01.699 letting the baby yell at night and keeping mother and dad calm. 22:01.700 --> 22:04.166 Or going into much more deeper things, right? 22:04.166 --> 22:08.666 You're our expert on family dynamics and family therapy. 22:08.666 --> 22:11.299 [Dr. Ray Mailloux:] There's no hard, fast answers to that kind of thing. 22:11.300 --> 22:13.300 I, as Glenn said. 22:13.300 --> 22:15.166 You try the simple things first, 22:15.166 --> 22:16.032 and you make sure 22:16.033 --> 22:19.899 that the parents are aware of what… what might be expected of a baby. 22:19.900 --> 22:22.100 You start to talk to a mother like that, 22:22.100 --> 22:25.000 and if you find that she's up three or four times a night. 22:25.000 --> 22:27.833 When she's maybe felt, really, 22:27.833 --> 22:29.699 there's nothing particularly wrong with the baby, 22:29.700 --> 22:31.733 and she picks it up for a few minutes or gives it its soother 22:31.733 --> 22:34.399 and it goes back to sleep and wakens another hour later. 22:34.400 --> 22:39.200 And then if you find that the husband is putting pressure on the mother. 22:39.200 --> 22:41.900 To get up and shut that kid up 22:41.900 --> 22:43.633 so he can sleep for the rest of the night. 22:43.633 --> 22:46.533 [Dr. Gary Gibson:] Sort of aggravating the stress, even further… 22:46.533 --> 22:48.499 [Dr. Ray Mailloux:] You begin to wonder if she's getting enough support 22:48.500 --> 22:51.000 and then of… sometimes you get into an area like that, 22:51.000 --> 22:52.766 and when you start asking about their relationship, 22:52.766 --> 22:56.332 you get into a whole can of worms. 22:56.333 --> 22:58.499 [Dr. Gary Gibson:] The other thing, I keep seem to be the one 22:58.500 --> 23:00.566 to talk about practicalities of time and so forth. 23:00.566 --> 23:04.266 But what about the use of the time in a visit? 23:04.266 --> 23:06.999 You know, if you start getting into this kind of thing, 23:07.000 --> 23:09.833 isn’t that going to shoot most of the time for the visit? 23:09.833 --> 23:12.533 [Dr. Ray Mailloux:] Well, it brings you to a whole sort of philosophical point 23:12.533 --> 23:14.366 as to just what you should be doing. 23:14.366 --> 23:22.232 Should you be putting out time energy and digging into the baby's patterns 23:22.233 --> 23:25.533 and the parental patterns, the family patterns and so on. 23:25.533 --> 23:27.899 Or should you be just doing the physical 23:27.900 --> 23:30.700 and organic [?] part of it? 23:30.700 --> 23:33.266 [Dr. Glenn Gibson:] Certainly, if you dig deep enough in any family, 23:33.266 --> 23:35.066 I think you're gonna find troubles. 23:35.066 --> 23:38.166 [Dr. Ray Mailloux:] Well, it… every family has difficulties at times. 23:38.166 --> 23:43.166 [Dr. Glenn Gibson:] It's probably, I guess, if it's causing a significant upset in the whole family, 23:43.166 --> 23:47.166 then that's the kind of thing that I certainly go after. 23:47.166 --> 23:49.432 [Dr. Ray Mailloux:] All right. 23:49.433 --> 23:53.066 [Dr. Gary Gibson:] We, uh, we didn't quite finish sort of rattling off 23:53.066 --> 23:55.432 the vegetative functions, and perhaps before we wind up, 23:55.433 --> 24:01.299 we should mention the slightly older groups. As we're not just talking about well baby visits. 24:01.300 --> 24:07.500 Um, certainly Ray’s last point of using the time I very much agree with, too. 24:07.500 --> 24:11.300 We’ve… we've deliberately structured the program this evening 24:11.300 --> 24:12.833 to show you extremes. 24:12.833 --> 24:17.299 Not necessarily either one of them being totally right or wrong. 24:17.300 --> 24:19.766 But we feel that more of the time 24:19.766 --> 24:23.132 and more directed questions probably are indicated. 24:23.133 --> 24:25.466 Just to… Just to finish off. 24:25.466 --> 24:28.732 Sorry, I'm going to say that as you get into the middle age groups, 24:28.733 --> 24:32.766 it's probably more commonly you start getting the tummy ache, 24:32.766 --> 24:36.899 headache problems. Maybe toilet training in the two- to three-year-old's. 24:36.900 --> 24:38.700 And then more and more difficulties 24:38.700 --> 24:40.666 with GI and headaches and so forth 24:40.666 --> 24:42.666 up to the early pre-teens. 24:42.666 --> 24:44.599 Those always, I think, should be a tip-off 24:44.600 --> 24:47.400 that there may be either child stresses 24:47.400 --> 24:49.833 or… or family difficulties as well. 24:49.833 --> 24:54.733 [Dr. Ray Mailloux:] When we initially sat down to consider the content of this program. 24:54.733 --> 25:00.166 We thought there were two areas we really wanted to deal with. 25:00.166 --> 25:03.032 One was that of considering 25:03.033 --> 25:06.933 de-emphasizing the physical examination part 25:06.933 --> 25:10.166 of the well childcare and the immunization part of it. 25:10.166 --> 25:13.199 And putting our money and our energy 25:13.200 --> 25:15.833 on the monitoring of the growth and development 25:15.833 --> 25:18.233 in their achievement of milestones. 25:18.233 --> 25:21.033 And the other area we wanted to look at 25:21.033 --> 25:27.066 was to consider how appropriate is to dig, um, 25:27.066 --> 25:32.066 quite deep into the relationship between the mother and the child 25:32.066 --> 25:34.799 and the, if necessary, the mother and the father. 25:34.800 --> 25:39.500 It can be time consuming. It can also be very interesting. 25:39.500 --> 25:42.533 Another thought we'd like to leave you with is 25:42.533 --> 25:47.299 where the nurse practitioner could fit into well childcare. 25:47.300 --> 25:49.633 In our own set-up, 25:49.633 --> 25:56.266 we just not set things up so that we can… we can do this. 25:56.266 --> 25:59.399 But certainly the nurse practitioner might be able to do a lot of these things 25:59.400 --> 26:05.933 while we were dealing with some illness in another room. 26:05.933 --> 26:08.833 As you've probably been aware, the 26:08.833 --> 26:11.466 initial film parts were role-played, 26:11.466 --> 26:13.032 and we'd like to thank our nurse, Karen Wilson. 26:13.033 --> 26:17.933 And mother, Mrs. Pat Miller and baby Shane for their part in it. 26:17.933 --> 26:21.733 We hope that we've given you something to think about 26:21.733 --> 26:24.199 with this program tonight. 26:24.200 --> 26:27.666 [Narrator:] If you are interested in participating in the evaluation 26:27.666 --> 26:29.999 of the Health Care Today television programs, 26:30.000 --> 26:32.066 or if you would like further information 26:32.066 --> 26:34.366 on the program's plan for this year. 26:34.366 --> 26:37.166 Please contact Health Care Today. 26:37.166 --> 26:41.866 Care of Jan McHugh: 2E4 McMaster Medical Center, 26:41.866 --> 26:50.599 or phone 525-9140. Extension 2489 or 2110. 26:50.600 --> 26:55.266 [Music] 26:55.266 --> 27:00.799 [Narrator:] Health Care Today was produced in cooperation with CHCH TV. 27:00.800 --> 27:02.400 McMaster University. 27:02.400 --> 27:04.600 The Ontario Medical Association. 27:04.600 --> 27:06.133 Mohawk College. 27:06.133 --> 27:08.466 The Ontario College of Family Physicians. 27:08.466 --> 27:11.099 And the Hamilton Academy of Medicine. 27:11.100 --> 27:14.200 [Photography and Graphics; Audio Visual Services, McMaster University] 27:14.200 --> 27:20.200 [Music continues]