Pregnancy and Early Neonatal Period - Case Study Example

PEDIATRICS PART – A I. FAMILY DATA: - The infant selected for my study is of an Australian origin. Father is an Australian and the mother is Chinese. The mother is of age 26 and is currently a housewife. Doing her master degree on Saturdays she wishes to work and earn at the time when the baby attains 1 or 1.5 years. There is a small difference of opinion between the couple in the female partner going away for employment. II. FAMILY DYNAMICS: - The role of Australian father is chiefly economy oriented. He is of the view that his wife need be a housewife until the baby attains the age of 4 years, when he can be sent to kinder garden. He focuses mainly on the financial impact in the upbringing of the child as the cost of child care in Australia is high and supposes that any income earned by his wife’s early employment would be forced to be paid in the costly child care alone. Partly this view of him is justified because in addition to the fiscal issue early employment of the mother would enforce avoidable physical separation of the infant from parents. The mother’s intention to go to work at the child’s age of 1 or 1.5 does not imply any diminished care orientation. However, the pragmatic inconveniences in bringing up the child at this stage are not foreseen by her. The assistance rendered by her mother during the birth time would not be quite available nor be accessed easily after one or two years. This should have been given weight in assessing future modalities. Hence the father’s wish of his wife going for a job at the schooling age of the child is acceptable, although he too does not fore see the types of inconveniences that my arise in due course of bringing up of the baby. Services of the grand parents (father side) of the baby can be harnessed by the mother of the baby to the extent possible, as there exist in some lingual communication delay. The actual requirement of the baby at a particular time need be expressed to her mother-in-law or father-in-law, for which the mother’s communication skill in Australian language accent may be a hurdle. Moreover, the father side grand parents’ ability to understand Chinese or Chinese accent in her English can be considered too wanting. In this view, the mother’s wish to go away for a job can be considered right as she may gain some more knowledge and language of the soil at an early stage. III. PREGNANCY AND EARLY NEONATAL PERIOD: - The period of Ultrasound screening during pregnancy suggested by Randomized Clinical Tests (RCT) and population based studies reveal that screening for fetal abnormalities is highly effective when performed at 18-20 weeks of pregnancy. In the case of the child under study the same had been carried out 12 weeks during when palpable abnormality could not be assessed. The improper timing of the Ultrasound screening can be consoled on the findings of Haresh Kirpalani (1999) that Ultrasonography is not 100% precise. (Haresh Kirpalani, et al 1999) The APGAR score of the infant 9 points both at 1 min and 5 min was indicating that the boy was normal in good health. The lump on the right side of the groin and the undescended testicle found by the midwife during routine check up need not be feared simply because of the fact that mum had not initially noticed. As far as the infantile hydrocele is concerned, the medical world is generally of the view that overly aggressive therapy for neonatal hydrocele is to be avoided because many of these hydroceles resolve on their own as the time passes. Moreover, surgery if done imminently would affect the vas deferens and testicular vessels, which may result in testicular atrophy. (William Taeusch. H, et al 2005) Restoration of glucose level at 30th week which went high at 28th week revealed that the gestational diabetic of the mother is bearable and not forthcoming. Similarly low vajinal swab indicated that the mother and child were not prone to the attack of the Group B Strep bacteria. The sore nipples suffered by the mother might be due to the use of pacifiers. The best treatment for sore nipples is generally prevention. Sore nipples are usually due to one or both of the two causes. That is, either the baby is not positioned and latched properly, or the baby is not suckling properly or both. Fungal infection may also cause sore nipples. The soreness caused by poor latching and ineffective suckling may be treated by proper positioning and latching. IV. GROWTH: - The growth pace of the boy was steady and getting uniform momentum over the period of 7 months from birth. Excepting an initial drop in the weight of the baby immediately after discharge everything including the weight went up steadily. The growth in length and head circumference of the baby is represented below graphically followed by the graphical representation of the weight growth. As the weight loss immediately after discharge had some practical and allowable grounds and the loss was negligible, the same is not given representation in the graphic representation thereby beginning the chart from 3 month. . The baby at 3 month noticed sudden prolonged sounds like the noise of mixie or vacuum cleaner and turned the head towards the noise. During the pause the baby stared a while and on resumption of the sound the baby boy began to listen the sound again. This had been tested by keeping the television in sound mode and tuning to mute alternatively. They boy turned his head towards the direction of the television whenever the sound began. At 6 month he showed development in his audibility by giving out a smile for his mother’s voice and father’s voice in the evening time. Whenever a new voice was heard the baby began to listen attentively. Fine development in his auditory motor system at 7th month was established when he began to listen attentively any familiar sound if given in a very low decibel. V. DEVELOPMENTAL ASSESSMENTS AND MILESTONES: - Milestones of developmental assessment involve chiefly three domains. They are: -- 1. Motor. a. Gross motor. b. Fine motor. 2. Speech and Language. 3. Cognition & 4. Personal-social/Adaptive. Gross motor movements of the infant during 6th month comprised some five to six movements like sitting independently, creeping on tummy, crawling with hands and knees, pulling to a stand, cruising. Fine motor movements are relatively low in number but these movements increase the concentrating/focusing skill of the baby. Transferring objects, raking grasp, finger feeding and primitive and neat pincer are a few of this kind of motor movements. Gross motor movements can not be taken granted as an indication of intelligence. Infants with poor gross motor movements are found with tangible intelligence and at the same time mentally retarded kids were showing usual gross motor movements pertaining to their age. The boy of our study expressed normal gross motor movements like grasping the objects sucking his fingers and the finger of parent when brought near his mouth. Social/emotional milestones are classified in many studies that excepting the social smiling by the infant at first 6 weeks in sensorimotor phase, all other movements begin in the month of 9 starting from object permanence, stranger anxiety and affective sharing. This is mostly because the mother and father alone become the chief environment of an infant. But the baby in our study had an advance development of these developmental milestones and could identify his mother and tried to attach with her. Mothers’ emotional developments were chiefly the specific base of the infant. Language/Speech skills too began from 3rd month and assumed a drastic development during 6th month. Right from babbling to one step command with a gesture the infant crossed a fast track of understanding language. The trajectory of such speech/language milestones comprised gesture games, uttering non-specific and then specific dada/mama, and understanding ‘No’. Of these the understanding of ‘No’ required very small amount of stimuli for the baby to grasp the meaning of ‘No’. This is because presenting the contrasting/contradicting environments was relatively feasible for the mother and father that became easily conceivable for the boy baby. V.1. Infant pointing: Infant pointing is the first attempt a child makes to convey his thought. Exact location of the intentionality in the baby’s mind is not easy to fix. However, pointing gestures form the platform on which linguistic communication rests and paves way for later learning of language. (Susan Goldin-Meadow, 2007). Infant pointing movement of the boy in study made comparison of some previous researches. Michael Tomasello et al (2007) go along with the above findings of Susan Goldin-Meadow, wherein they believe that children’s early linguistic skills are built on this already existing platform of pre-linguistic communication. The study conducted by this team found that when 12-month old infants pointed for an adult they were in some sense trying to influence the mental states. (Michael Tomasello et al 2007). Barbara D’Entremont et al (2007) however argue that infant pointing is not possible until 18-24 months of age on the ground that to understand communicative intent infants must have a concept of self and others as intentional agents. (Barbara D’Entremont And Elizabeth Seamans, 2007). But this view of Barbara et al can not be accepted in toto because , with reference to Richard Goldbloom (2003) in the developmental assessment by Sarah Shea, an infant at the age of 5 months itself is capable of distinguishing strangers from family members. (Richard B. Goldbloom, 2003). However, Juan-Carlos Gómez (2007) gives a balanced interpretation on infant pointing accounting for the complexity of infant pointing without attributing multilayered mind reading to infants. He adopts a midway between lean and rich interpretations based on the notion of intentional reading of behavior without simultaneous attribution of unobservable mental states. (Juan-Carlos Gómez, 2007). The boy of our study was able to point her mother when she neared him. Thus we are able to go along with the finding of Sara Shea. Understanding the age old developmental assessment theories would be nicer in case of an inter-cultural upbringing. Although Sigmund Freud was the father of Psychoanalytical theory and related school of thoughts focusing chiefly on adults, many of his followers have attempted to use his theories for assessing infantile developments too. Of those who did not see eye to eye of Freudian views, Alfred Adler, who was originally associated with Sigmund Freud was eminent. In Adlerian point of view, the child from day-1 interacts with the people (mostly the parents and especially the mother) about him and is in the process of learning the rules and limits of his society. The child develops some attitudes and convictions from such interactions. Family atmosphere and family constellation must necessarily be taken into account for assessing infantile developments. The social attitudes within the family certainly influence the attitudes of the baby which he develops at a later stage or period. While the family atmosphere is not a direct determinant of behavior, it does present the baby in competitive and cooperative atmospheres which he may choose to adopt or reject. Rudolf Dreikurs, an Adlerian, believed that it was important to recognize the child’s goals that may be either passive or active and may use either constructive or destructive. Thus Dreikurs (1957) postulated four types of behavior patterns. They are: - (i) active-constructive (ii) active-destructive (iii) passive-constructive and (iv) passive-destructive. (Rudolf Dreikurs, 1957,). Under these postulations although it may not be cent percent perfect to assess the trait of the boy of our study who is just seven months old, we may assume the boy to assume an active-constructive behavior pattern. This assumption is based on the fact that the goals of the baby is currently satisfied then and there that keeps him active in switching over to next phases of learning processes and because of the fact that the parents are keeping their differences under control thereby a negative attitude in the baby is not nurtured. VI. NUTRITION INFORMATION: - Breast feeding the baby begins early in the morning by 3 to 4 A.M. and is continued 2 hourly during day time and the pace is kept 4 hourly in nights. At 4th month of weaning solid food had been started with banana, carrot and smashed sweet potato. Breast milk alone is not able to provide sufficient amounts of all the nutrients needed to maintain growth of the baby after six months. Increasing needs of calories and protein for children could not be met the diminishing out put of mother’s milk. Milk is also a poor Vitamin C and supplementation with fruit juice is essential. Iron stores in the liver of the infant would last only up to 4-6 months. Hence iron rich foods should be given at least from six month onwards. If the baby is to maintain the expected rate of growth and remain healthy and well nourished, supplementary feeding is to be restored to round about the sixth month of life. Early introduction of supplements before six months of age is not associated with any beneficial effects on infant growth. However, it is possible that introduction of supplements results in reduction in suckling stimulus and therefore reduction in milk output resulting in shorter duration of lactation and shorter duration of lactational amenorrhea and inter-pregnancy interval. Nutrient density of weaning foods of western diet is 1.0 kcal/g of food and in Asia the nutrient density is 0.25 kcal to 0.4 kcal/g. Hence calorie dense foods like malted food should be given to the boy during the period of weaning session. Weaning food should give at least 10% of the energy as protein. (Srilakshmi. B. 2005) VII. HEALTH REPORT: - The health report of the mother and baby at the time of discharge suggests no abnormality in any stage up to discharge. The Apgar score and the newborn examination results done before discharge are perfectly normal. A loss in weight by 120 gms on discharge is highly negligible and understandable due to factors like hospital environment. Gradual increase in weight and other scores from day 5 confirms this. Day 5 weight 3310gms. Day 9 :3840 g, 53cm, 35.5 cm. 4th week: 4650g, 56cm, 37.7cm 6th week: 5750g, 59.6cm, 39.5cm 8th week: 6450g, 61.5cm 40cm 3 month: 7210g, 63cm, 42.5cm 4 month: 8070g, 66cm, 44 cm 5 month: 8400g, 69cm, 44.4cm 6 month: 9200g, 71cm, 45.4cm 7 month: 9800g, 72cm, 46 cm VIII. IMMUNIZATION STATUS: - The immunization records too are quite right and appropriate in timing. @ birth: hepatitis B was given @2 month: DTP-IPV 1 ( Diphtheria/tetanus/pertussis/inactivated polio) @4 month: DTP-IPV 2 ( Diphtheria/tetanus/pertussis/inactivated polio) Hib 2---hepatitis B 2 Pneumococcal 2 @6 month: DTP-IPV 23( Diphtheria/tetanus/pertussis/inactivated polio) Pneumococcal 3 It would be sufficient if the mother and baby attend a well baby clinic periodically up to 12th month and get the kid immunized up to his preschool and kindergarten age. IX. AGENCIES USED: - The agencies used are: hospital (mainly for pregnancy and birth) and local maternal & child health centre in the area: this facility help parents understand children’s health &development and assist parents in future when it’s time to enroll for a preschool program and when starting school. Getting assistance and advice from grandmas can not be ruled out straight away only on the ground that they are not scientifically proved. Their traditional treatment and process the basis of which are not attempted to be tested scientifically still work well and many medications of present days emerge from the herbs and related chemicals. PART- B: - Instructions: - Synopsis: - My visits to the family to acquire information on the child were going well as I have done the job every time after obtaining an appointment with the parent. On each visit I made specific questions on the developments of the child, which gave no room for embarrassment over oblivion on the part of the mother. She was highly cooperative in answering my questions as far as the health report of the kid was concerned. The father of the boy whom I was able to meet during week ends also gave me some fruitful information regarding his expectation of the baby’s development in future. On meeting all the three, that is the father, the mother and the mother-in-law, I found that the inter-continental cultural differences were found nil in as much as the well being of the baby was focused. As such I found very less difficulty in assessing the bay’s developments and my process did not pose any problems. To sum up I can say with certainty that the parents view on development, both physical and psychological, of the bay was glaringly impacted by the attending nurses and midwifes. Since it was easy for the mother to acquire any information or advice at ease from a nurse or midwife than from a doctor who had to be approached at fixed intervals and appointment. Breastfeeding is the most crucial and important aspect in giving a start to the life of the baby on the earth. The crying and subsequent use of soother/dummy indicates that the baby was not able to be cared for immediately at birth. A study conducted by Li-Yin Chien and Chen –Jei Tai (2007) reveals that a very quick initiation of breast feeding, say within 30 minutes of delivery was associated with higher odds of breast feeding. The role of health care professionals is also crucial in supporting the mothers to increase their breast feeding. (Li-Yin Chien and Chen –Jei Tai, 2007). Hospital practices enhance the efforts in mothers to have greater propensity for breastfeeding. Erin K. Murray et al (2007) suggest some five good practices adhered to by the hospitals in Colorado. The practices are: - 1. Breastfeeding within the first hour of delivery. 2. Emphasizing breast milk only. 3. Infant rooming-in. 4. Discouraging pacifier use. 5. Receipt of a telephone number for use after discharge. (Erin K. Murray et al 2007). Influence of grandmothers, breastfeeding techniques and sore nipples have in many cases become the determinants for the cessation of breastfeeding well before 6 months of delivery. (Lilian Cordova do Espírito Santo, 2007). The crying of the boy was found pacified using dummy, which the mother comments work well. But the ill effects of such pacifiers are not taught to the mother and hence the use of dummy resorted to. Encouraging birth plan system would mitigate many problems in delivery, since women are provided with their rights to opt the method of delivery. (Beverley Chalmers, 2007). Four sub classes of attachment are stipulated in studying the attachment pattern of children. They are: - (1) Secure attachment (2) Avoidant attachment (3) Resistant attachment and (4) disorganized/disoriented attachment. Secure attachments can lead the child to be more comfortable exploring, which leads to better learning and can lead to more intimate love relationships in later life. (Stephen M.Kosslyn & Robin S. Roenberg, 2001). The boy of our study has a secure attachment with his mother. The view of the Australian father that the independence of the child could be forfeited if allowed to sleep with his mother has to be revisited. Asian and western cultural ideologies should be viewed with an eye on the molding of a good character in the child. As long as the boy is in sensorimotor phase, it would be nice to let him be with his mother, during when it may be fair to assess what type of attachment the boy has on his mom. After the onset of the preoperational phase or in the middle of the preoperational phase the boy can be allowed to sleep in his room depending upon the type of attachment he had on his mother. However, the mother-in-law’s view that the child must be made to sleep either with mother or with father can not categorically be rejected as the theory of attachment holds good with father too. Parenting structure and style of parenting decide much of the development in infants and children up to the age of 5. David A.Nelson et al (2006) found that physical coercion was predictive of aggression in boys while psychological control was primarily associated with aggression in girls. They established that aversive parenting in Chinese cultural context was assessed to contribute to the development of physical and relational aggression in preschool kids. (David A Nelson et al 2006). Psychological control in parenting style is the main determinant manipulative of the children’s thoughts, feelings and their attachment towards their parents. Bobby Walling et al (2006) hypothesized three types of psychological controls as parenting cognitions. They are; - low perceived control, sensitivity to hurt and disapproving attitude to negative emotion. In their study they found that sensitivity to hurt and disapproval to negative emotions were associated with more frequent use of psychological control. (Bobby R.Walling et al 2006). The psychological controls of parents were found in many studies to have impact at the earlier stage of adolescence. Arne K. Albrecht et al (2007) made a hierarchical regression analysis (HR) on 530 adolescents and found that their perception of parent’s psychological control at baseline did not predict changes in their aggression over 2 years of experiment. But they fixed higher physical aggression in the earlier period of adolescence during when they estimated greater control of parents’ psychological controlling especially that of the mothers, which scored much. (Arne K. Albrecht et al 2007) Style of parenting is the deciding element for the development of a child. Children including infants feel valuable and loved. They receive attention for positive behavior. They understand from the caregiver what is okay and what is not okay. During infancy, non-okay signals from mother or father if found inconvenient they begin to cry to express their protest. Parents ought to expect such protests and veer the attention of the kid in proper manner. Sometimes the infants’ inconvenience would be justified like tight clothing. At such occasions the needs of the infant have to be necessarily satisfied without imposing any adult procedural formalities. During the entire sensorimotor phase—infancy—everything and every movement away from the skin of the baby is the source of knowledge base on which the development of the child is built. Mother is the chief feeder, inculcator and protector of the child. Father comes in to the picture relatively in less frequency and the children are capable of understanding that the father’s intrusion is crucial in timing. Intra-parental differences certainly affect the physic and psychic developmental aspects of the infant. Hence a consensus between the parents in upbringing the child is obligatory. Parental attachment is decided by the time spent and its frequency by the parents with the kid. The father of our study is found to spend his time in normal working days for merely an hour or two in the night with the kid. However during week end he spends much time with the kid. This would have the impact on the development of the child that paternal attachment is not far away. The involvement of the father in our study in care giving is above average. That is delineated in his non oppressive decision making. Mostly he follows the decision of his wife. The parents of the infant are ideally cooperative to one another focusing chiefly the well being of the infant. At 4th month the father wanted the child to walk and tried to inculcate the practice. Although the mother knew that it was a bit early for the kid to walk, she did not enter into any argument or altercation and allowed the father of the infant to have his own experience but simply made a mention of the infant’s inability to walk at the period. Difference of opinion between the mother and father in respect of sleeping arrangement of the baby can be resolved focusing chiefly on the molding of a good character in the boy and processing on an apt psychological base for the purpose. Recent studies by L.M.Forbes et al (2007) also confirm this. 71 infants at the age of 12-24 months were subjected to a longitudinal study and the links between disorganization and atypical maternal behavior were examined. They found that at both ages, disorganization and maternal disrupted behavior were significantly correlated. They also found that organized and undisrupted maternal behavior were more stable. The results of the team’s findings provide substantial support for existing theories linking anomalous maternal behavior to the development of disorganized attachment and thus taking the form of an efficacious tool for assessing attachment and maternal behavior in toddler hood. In all these studies the role of mother predominates as a primary giver. (L. M. Forbes et al 2007). Hence, getting to the bottom of the conflict among the couple regarding the baby’s sleeping arrangement must necessarily must have to be focused only on the period of leaving the kid independent and not simply sticking on to their own ideas and conventions of their origin. . * * * * * * * * * * * Reference list— Arne K. Albrecht, Nancy L. Galambos, S.Mikael Jansson, 2007, “Adolescent’s internalizing and aggressive behavior and perceptions of parents’ psychological control: a panel study examining direction of effects”, Journal of Youth and Adolescence, Vol. 36, No. 5, July 2007, Springer Netherlands Barbara D’Entremont And Elizabeth Seamans, 2007, “Do Infants Need Social Cognition to Act Socially? An alternative Look at Infant Pointing”, Child Development, Vol. 78, No. 3, 723-728 Beverley Chalmers, 2007, “Let Us Not Ignore Womens Concerns and Wishes from Developing Countries”, Birth, Volume 34 Issue 1 Page 51-52, March 2007, Penny Simkin, 2007, “Birth Plans: After 25 Years, Women Still Want To Be Heard”, Birth, Volume 34 Issue 1 Page 49-51, March 2007 Bobby R.Walling, Rosemary S.L.Mills, Wendy S.Freeman, 2006, “Parenting Cognitions Asociated with the Use of Psychological Control”, Journal of Child and Family Studies, Online journal, December 2006, ISSN: 1573-2843, Springer Netherlands David A Nelson, Craig H Hart, Chongming Yang, Joseph A Olsen, Shenghua Jin, 2006, “Aversive Parenting in China: Associations With Child Physical and Relational Aggression”, Child Development, Volume 77 Issue 3 Page 554-572, May/June 2006 Erin K. Murray, Sue Ricketts, Jennifer Dellaport, 2007, “Hospital Practices that Increase Breastfeeding Duration: Results from a Population-Based Study”, Birth, Volume 34 Issue 3 Page 202-211, September 2007 Haresh Kirpalani, Gerald Gill, John Mernagh, 1999, “Imaging of new born Baby”, pp 156-157, Churchill Livingstone, Philadelhia Johnson, S. 2000, “The recognition of mentalistic agents in infancy, Trends in Cognitive Sciences, 4, 22-28 Juan-Carlos Gómez, 2007, “Pointing Behaviors in Apes and Human Infants: a Balanced Interpretation”, Child Development, Vol. 78. No.3, 729-734 Lilian Cordova do Espírito Santo, Luciana Dias de Oliveira RD, Elsa Regina Justo Giugliani ,2007, “Factors Associated with Low Incidence of Exclusive Breastfeeding for the First 6 Months”, Birth, Volume 34 Issue 3 Page 212-219, September 2007 Li-Yin Chien and Chen –Jei Tai, 2007, “Effect of Delivery method and Timing of Breastfeeding initiation on Breastfeeding Outcomes in Taiwan”, Birth, Vol. 34. No.2, 123-130 L. M. Forbes, E. M. Evans, G. Moran, D. R. Pederson 2007, “Change in Atypical Maternal Behavior Predicts Change in Attachment Disorganization From 12 to 24 Months in a High-Risk Sample”, Child Development, Volume 78 Issue 3 Page 955-971, May/June 2007 Michael Tomasello, Malinda Carpenter, Ulf Liszkowski, 2007, “A New Look at Infant pointing”, Child Development, Vol 78, No. 3, 705-722 Richard B. Goldbloom, 2003, “Pediatric Clinical skills”, third Edition, pp 92, 103, In ‘Developmental Assessment’ by Sarah Shea, Saunders, London. Rudolf Dreikurs, 1957, “Psychology in the Classroom”, Harper and Row Publisher Inc, New York Srilakshmi. B. 2005, “Dietetics”, V Edition, New Age International (P) Ltd, Publishers, (formerly Wiley Eastern Limited) New Delhi, India. Stephen M.Kosslyn & Robin S. Roenberg, 2001, “Psychology: the brain, person and the world”, pp 406, Allyb and Bacon, Boston. Susan Goldin-Meadow, 2007, “Pointing Sets the Stage for Learning Language—and Creating Language”, Child Development, Vol. 78 No.3, 741-745 Virginia Slaughter, Candida C. Peterson, Emily Mackintosh 2007, “Mind What Mother Says: Narrative Input and Theory of Mind in Typical Children and Those on the Autism Spectrum”, Child Development, Volume 78 Issue 3 Page 839-858, May/June 2007 William Taeusch. H, Robert A. Ballard, Christine A.Gleason, 2005, “avery’s Diseases of the New born”, In ‘ developmental abnormalities of Genitourinary Systems’ by Stephen A. Zderic, Saunders/Elsevier, Philadelhia, ISBN: 81-8147-592-5 Read More