Prenatal Period

Education and counseling of pregnant

women are important to ensure the
outcome of a healthy baby
Areas of Concern
A. Maternal nutrition, which includes
folic acid supplementation
B. Newborn care and procedure at birth
including the Essential Intrapartum
and Newborn Care (EINC)
C. Breast feeding
D. Tetanus toxoid immunization for the
mother
E. Prevention of smoking, alcohol intake
and exposure to teratogens
F. Anticipatory guidance to decrease
the risk of injury and identify risk
factors for child maltreatment
Newborn Period
Every neonate must be totally
appraised at birth and monitored
daily until discharge
Latching on and breastfeeding must
be initiated during the first 30
minutes to 1 hour after birth since
colostrums is the perfect first food
EINC should be implemented
Newborn screening test
The following information should be elicited:
A. Parents education and profession
B. Attitude regarding the pregnancy
C. Planned disciplinary method or child
rearing approach
D. Financial security
E. Family support system
F. Other factors that may be vital in the
assessment of the childs future
exposure to or prevention of neglect,
maltreatment or violence
Essentials of Intrapartum and Newborn Care
Administrative order 2009-0025 was
signed in 2009
Mandates implementation of the EINC
protocol in both public and private
hospitals. Likewise, the Unang Yakap
was also launched.
The EINC practices are evidencebased standard for safe and quality
care of birthing mothers and their
newborns, within the 48 hours of
intrapartum period and a week of life
for the newborn.
EINC Practices during the Intrapartum Period
1. Continuous maternal support, by a
companion of her choice, during
labor and delivery
2. Mobility during labor
3. Position of choice during labor and
delivery

4.
5.

Non-drug pain relief, before offering

labor anesthesia
Spontaneous pushing in a semiupright position

Nutritional and developmental surveillance

Physical activity
Emotional, social and physical growth
Sleep
Safety
Parental well-being
Family milieu
Vitamin K administration
Eye prophylaxis
Immunizations: Hepatitis B and BCG
Newborn hearing screening test
Unnecessary Interventions in Newborn Care
1. Routine suctioning
2. Early bathing
3. Routine separation from the mother
4. Foot printing
5. Application of various substances to
the cord
6. Giving pre-lacteals or artificial infant
milk formula or other breast milk
substitutes
Unnecessary Interventions Eliminated During
Labor and Delivery
1. Enemas and shavings
2. Fluid and food intake restrictions
3. Routine insertion of intravenous fluids
4. Fundal pressure to facilitate 2nd stage
of labor
5. Episiotomy will not be done, unless
necessary
6. Active management of 3rd stage of
labor
7. Monitoring the progress of labor with
the use of pantograph
Benefits of Breast Milk
1. Safe, sterile and always available
2. Contains all the nutrients needed to
fully sustain the growth and
development of the baby from birth
to 6 months of age; and after 6
months, still a good source of
nutrients when given with adequate
complementary foods.
3. Easily digested and absorbed;
efficiently used by the babys
immature system
4. Contains antibodies and substances
which protect the baby against
infection
5. Contains fats (DHA) which enhance
brain development and intelligence
of the baby
Breastfeeding
Mothers must be informed of the
following
1. Early initiation of breastfeeding

2.
3.

Exclusive breastfeeding up to 6
months
Continued breastfeeding up to 2
years

The Newborn Period (EINC)

1. Immediate and thorough drying of
the newborn
2. Early skin-to-skin contact between
mother and the newborn
3. Properly timed cord clamping and
cutting
4. Non-separation of the newborn and
mother for early breastfeeding
Unang Yakap (First Embrace)
Diseases included in 2008
1. Congenital Hypothyroidism (CH)
2. Congenital Adrenal Hyperplasia (CAH)
3. Phenylketonuria (PKU)
4. Galactosemia (GAL)
5. Glucose-6-Phosphate Dehydrogenase
Deficiency (G6PD)
6. Maple Syrup Urine Disease (MSUD)
Expanded NBS 2014: includes 22 more
disorders
Hemoglobinopathies
Organic acid, fatty acid oxidation and
amino acid disorders
Advantages of Breastfeeding
1. Promotes emotional bonding between
the baby and the mother
2. Protects the mothers health against
cancer (breast, uterus, ovaries),
obesity and post-partum hemorrhage
3. Promotes early return to prepregnancy weight
4. Gives the family big financial savings
The Universal Newborn Hearing Screening
and Intervention Act of 2009 (Republic Act
No. 9709)
Section 5: Obligation to Inform
Any health practitioner who
delivers or assists in the delivery,
of a newborn shall, prior to
delivery, inform the parents or
legal guardian of the availability,
nature and benefits of hearing
loss screening of infants 3
months old and below
Section 6: Obligation to Perform
Newborn Hearing Loss Screening and
Audiologic Diagnostic Evaluation
All infants born in hospitals shall
be made to undergo newborn
hearing loss screening before
discharge, unless the parents or
legal guardians object to the
screening

Section 7: Infants who are not born in

hospitals should be screened within
the first 3 months after birth

Newborn Screening Act of 2004

Section 5: Obligation to Inform
Any health practitioner who
delivers or assists in the delivery,
of a newborn shall, prior to
delivery, inform the parents or
legal guardian of the availability,
nature and benefits on newborn
screening
Section 6: Performance of Newborn
Screening
Newborn screening shall be
performed after 24 hours of life
but not later than 3 days from
delivery
Follow-up Visits
1. Assess the infants general health
a. Hydration
b. Presence of jaundice
c. Adequacy of urination and
defecation patterns
2. Identify any new problems
3. Review feeding patterns and
technique
4. Reinforce maternal or family
education in infant care
5. Assess the quality of mother-infant
interaction and the details of infant
behavior
6. Review the outstanding results of
laboratory tests before discharge
7. Perform screening tests if not yet
done
8. Suggest and encourage compliance
to the recommended schedule of
periodic follow-up and preventive
care
Discharge of Healthy Term Newborns
Term, well newborns with no
problems, may be discharged 48
hours after delivery and may be
returned for the next preventive care
after 2 weeks
Minimum Criteria for Discharging
Newborns before 48 hours:
1. Uncomplicated antepartum,
intrapartum and post-partum
courses for both mother and
baby
2. Vaginal delivery, singleton,
completed 37 weeks, AGA
3. Normal and stable vital signs
during the preceding 12 hours

4.
5.

6.
7.
8.

(RR <60min, CR 100-160/min.

axillary temperature 36.5-37.4
degrees centigrade
Has urinated and passed at least
1 stool
Has documented proper latch,
milk transfer, swallowing, infant
satiety and absence of nipple
discomfort
Normal physical examination
Educability and ability of the
parents to care for their child
Must follow-up within the next 48
hours

Infancy and Early Childhood

Answering parents questions is the
most important priority of the wellchild visit
For each visit, there are topics that
are specific to individual children
based on their age, family situation,
health condition or parental concern
Middle Childhood and Adolescence
Attending to developing autonomy
require fostering a clinician-patient
relationship separate from the
clinician-child-family relationship
There is an increasing need for
privacy and confidentiality as the
child ages
Health behaviors that most significantly
impact adolescent and adult morbidity and
mortality
1. Inadequate physical activity
2. Poor nutrition
3. Sexuality-related behaviors
4. Substance use and abuse
5. Unintentional injury-related behaviors
6. Intentional injury-related behavior
Nutrition Monitoring and Surveillance
Counseling regarding breastfeeding
that was started during the prenatal
period must be continued during well
child visits.
Mothers must be encouraged to
exclusively breastfeed up to 6
months and continued on up to 2
years and beyond
Children must be taught the value of
eating healthy foods in a balanced
diet as well as avoiding unhealthy
foods
Giving of foods that are too sweet,
too salty, or too oily should be
avoided
The food pyramid crafted by the
Philippine Society of Pediatric
Gastroenterology and Nutrition is a
guide for physicians and parents in
providing daily healthy diets for
children

Growth Monitoring
WHO Child Growth Standards
Reference standard for weight, height
and head circumference
Based on Z-scores which are
standard deviation scores
Developmental Surveillance
Social-Emotional Red Flags
Age
9 months
12 months
18 months
Any age

Red Flag
Lack of reciprocal vocalizations,
Failure to respond to name when
Lack of simple pretend play
Loss of previously acquired socia

Motor Red Flags

Age
4 months
9 months
18 months

Red Flags
Lack of steady head control while
Inability to sit
Inability to walk independently

Receptive Language
Age
Red Flags
2 months
Does not alert or quiet to sound
10 months
Does not respond to own name
12 months
Does not follow verbal
routines/games
15 months
Does not understand simple
questions
Does not stop when told No
18 months
Does not point to 3 body parts
Does not follow simple command
30 months
Does not follow 2 step commands
Expressive Language
Age
Red Flags
6 months
Does not coo
10 months
Does not babble
12 months
Absence of nonverbal
purposeful messages
16 months
Does not say 3 different
spontaneous words
24 months
Vocabulary of not more than
30-50 words
Does not produce 2-word
sentences
36 months
No simple sentences
42 months
Intelligibility to unfamiliar adult
at <50%
54 months
Not able to tell or retell a
familiar story
>72
Not fully mature speech sounds
months
Adolescent Health Care
Annual health screening and
preventive services are
recommended in this special
population

During the annual visit, the

adolescent should undergo the
following:
1. Complete history-taking and risk
assessment/screening using the
HEADSSS format
2. Physical examination
a. Tanner Staging or Sexual
Maturity Rating
b. Breast examination
c. Examination of the spine and
shoulders
d. Inspection of the genitals and
anus
3. Laboratory test
a. Complete Blood Count
b. Urinalysis on first encounter
c. For sexually active females
PAP smear; For sexually
active males serologic test
for syphilis
4. Immunization update
5.

Anticipatory guidance and

counseling
a. Self-breast examination for
females
b. Healthy lifestyle
c. Sexual behavior and the risk
of acquiring STDs including
HIV
d. Injury and accident
prevention

Expanded Program of Immunization

Objectives:
1. To reduce the morbidity and mortality
rates of the common EPI diseases
2. To reduce the incidence of neonatal
tetanus by providing pregnant
women with tetanus toxoid
Immunizations
A. Active Immunization
This involves the administration of all or part
of a microorganism or a modified product of a
microorganism, to evoke an immunologic
response that mimics that of natural infection
but usually presents little or no risk to the
recipient
Some vaccines provide nearly complete and
lifelong protection against disease, some
provide partial protection, and some must be
re-administered at regular intervals to
maintain protection
B. Passive Immunization
This entails administration of preformed
antibody to a recipient and unlike active
immunization, achieves protection for only a
short period of time
EPI Vaccines
1. BCG
2. DPT
3. OPV-IPV
4. Hepatitis B
5. Measles

6.
7.
8.

MMR
Rotavirus
Pneumococcal conjugate

Vaccine
BCG
Diptheria-Tetanus
DTaP
DTap-IPV/Hib
Hepatitis B
Hib conjugate
MMR
Rotavirus
Pneumococcal conjugate
Rabies
Varicella
Vaccine
BCG (1 dose)

Type
Live bacteria
Toxoids
Toxoid and inactivated bact
Toxoid and inactivated bact
polysaccharide-protein conj
Recombinant viral antigen
Bacterial polysaccharide-pr
Live-attenuated virus
Live-attenuated virus
Bacterial polysaccharide-pr
Inactivated virus
Live-attenuated virus
Earliest Age
At birth

DPT (3 doses)
6 weeks
OPV (3 doses)
6 weeks
Hepatitis B (3 doses)
At birth
Measles (1 dose)
6 months
MMR (1 dose)
15 months
Hib (3 doses)
6 weeks
Pneumococcal (3 doses)
6 weeks
Rotavirus (3 doses)
6 weeks
Screening for Eye or Visual Defects
A comprehensive ophthalmologic
examination is necessary for the
following:
A. Premature infants at risk for
Retinopathy of Prematurity (ROP)
1. <32 weeks age of gestation
2. Low birth weight <1500
grams
3. Infants weighing 1500 2000
grams with a stormy medical
course
B. Infants with metabolic disorders
C. Family history of retinoblastoma
D. Family history of congenital
cataracts
E. History of maternal infection
(rubella) or genitourinary
infection (STDs)
F. History of squinting, visual
difficulties
G. Vitamin A deficiency or history of
night blindness
H. Children with other impairments
Eye Screening
At birth, eye screening involves
checking for the presence of the
following:
1. Steady eyes
2. White lustrous conjunctiva
3. Clear cornea
4. Non-droopy eyelids
5. Pupillary reflex
6. Red orange reflex
Vision Screening
Visual Acuity Test

Interval

4 weeks
4 weeks
0-1-6 months

4 weeks
4 or 8 weeks
4 weeks

a.
b.
c.

For 3 month old infants should

be able to fixate and follow light
2.5 3 years old vision test:
LEA symbols
Older children E-test

Blood Pressure Monitoring

It is recommended that routine blood
pressure measurement for children
be started at 3 years of age
However, it must be done on all ill
patients and all patients at risk,
regardless of age
A child is normotensive if the BP is
<90th percentile for age, gender and
height percentile
Prehypertension in children: average
SBP or DBP levels that are equal to or
greater than the 90th but <95th
percentile
Hypertension in children: average
SBP and/or DBP equal to or greater
than the 95th percentile on 3 or more
occasions

children aged 12 months to 14 years

using:
a. Albendazole
12-24months: 200mg single
dose
24 months and above:
400mg single dose
b. Mebendazole
12 months and above:
500mg single dose
Both drugs should be taken on a full
stomach and are given every 6
months
Deworming must not be done in
children with:
a. Severe malnutrition
b. High grade fever
c. Profuse diarrhea
d. Abdominal pain
e. Serious illness
f. Previous hypersensitivity to
anthelmintic drug

Anticipatory Measures on Dental Health

Cleansing the infants teeth as soon
as they erupts with either wash cloth
or soft brush
The use of dental floss is important to
reduce inter-proximal caries
Educate parents on the following:
a. Cariogenicity of some foods and
beverages
b. Dental caries and its relationship
with prolonged bottle feeding or
bottle feeding while asleep

Preventive Dental Care Recommendations

The first dental visit should be done
at the time of eruption of the first
tooth and no later than 12 months of
age
A fluoride-containing toothpaste, as a
primary preventive measure, should
be used twice daily
Young children must be supervise
while brushing and should be taught
to spit out the toothpaste and to
avoid rinsing after brushing
Topical fluoride treatment:
a. Professionally applied topical
fluoride has been proven to
prevent or reverse enamel
demineralization
Preparation
b. Children at moderate caries risk
Drops: 15mg elemental
should receive treatment at least
iron/0.6mL
every 6 months
Drops: 15mg elemental
c. Those with high caries risk should
iron/0.6mL
receive the treatment more
Syrup: 30mg elemental iron/5mL
frequently

Anemia Prevention
Iron deficiency anemia is associated
with cognitive and psychomotor
abnormalities in children
At risk are those with poor nutritional
history and those with a past or
family history of anemia
A complete blood count is
recommended at least once between
the following time intervals:
1. 6 to 24 months
2. 2 to 6 years
3. 10 to 19 years
Iron Supplementation
Targets
Low birth weight
6 11 months
1 5 years
10 19 years

Tablet: 60mg elemental iron with

Recommend Use of Fluoride Toothpaste in
400mg folic acid
Children
Age group
Fluoride concentration
Guidelines on Deworming
(ppm)
The department of health
6 months to <2
1000ppm
recommends deworming for all
years

Minimum

Twice dail

2 to 6 years
6 years and above

1000ppm
1500ppm

Recommended Anticipatory Guidance Topics

for the Prevention of Violence against
Children
Topics
Infa Todd Presc
Sch Adoles
ncy ler
hool
ool
cence
Age
Domes
tic
violenc
e
Infant
crying
and
danger
s of
shakin
g
Positive
discipli
ne
Safety
in
others
homes
or with
other
people
Normal
sexual
behavi
or
Good/
Bad
touch
Bullyin
g
Peer
relation
ship
Mobile
phone
and
interne
t safety
Alcohol
and
substa
nce
abuse
Dating
violenc
e
Protective Factors

Stable family units can be a powerful

source of protection for children.
Good parenting, strong attachment
between parents and children and
positive non-physical disciplinary
techniques are likely to be protective
factors

Seven Steps to Protect Children

1. Learn the facts majority of sexual
offenders of children are family
members, friends and neighbors
2. Minimize the opportunity for sexual
abuse by eliminating or reducing oneadult/one-child situations
3. Talk about it teach your children
what parts of their bodies other
should not touch
4. Stay alert learn the signs of sexual
abuse, physical signs are not
common, emotional and behavioral
signs are more common, know the
textmates of your child
5. Act on any suspicion of abuse
6. Learn how to react to the knowledge
of abuse and offer support
7. Get involved use your voice and
your vote to make your community a
safer place for children
Screening for Tuberculosis
Screening for tuberculosis is targeted
among individuals who are at risk for
developing the disease
Mantoux Test: single puncture
tuberculin test, standard and
recommended method for screening
Mantoux or Tuberculin Test
0.1mL of either 5TU PPD-S or 2 TU
RT23
Injected intradermally into the solar
aspect of the right forearm
Measure the induration between 4872 hours after the injection
Induration is measured transversely
to the long axis of the forearm by
ballpoint technique
Positive reaction
1. 10mm induration or more
2. Induration of 5mm or > in the
presence of the following:
a. History of close contact with
a known or suspected case of
TB
b. Clinical finding suggestive of
TB
c. Chest X-ray suggestive of TB
d. Immunosuppressed condition
False Negative
1. Factors related to the person
being tested:
a. Anergy
b. Very young age (<6 months)
c. Recent TB infection
d. Overwhelming TB disease

e.
2.
3.
4.

Live virus vaccination:

measles, MMR, varicella
f. Immunosuppression
Factors related to tuberculin used
Factors related to the method of
administration
Factors related to error in reading
and recording

Physical Activity
A physical active lifestyle among
children and adolescent will be
carried into adulthood and reduce
health problems related to inactivity
Recommendations:
a. Age-appropriate physical
activities for 60 minutes daily or
on most days of the week
b. Discourage children form
prolonged periods of sedentary
activity for greater than 2 hours
per day

STD Screening for Adolescents

Annual health screening
a. Sexually active females: vaginal
wet mount and PAP smear
b. Sexually active males: serologic
test for syphilis
c. For both sexually active males
and females: non-culture test for
gonorrhea and chlamydia
Importance of Reading Aloud to Children
Physicians should advise parents
about the importance of reading
aloud to children during the first
years of life.
This helps the children to develop
language and literacy skills making
them ready to learn and read in
school