(18) Peds Reds Flashcards
Preterm infants are at risk for
both short-term complications (mainly respiratory and cardiovascular) as well as long-term sequelae (e.g., neurodevelopmental).
Late preterm infants are at
considerable risk for
prematurityrelated
complications
Postterm infants are at increased risk
of
perinatal mortality or morbidity
such as asphyxia and meconium
aspiration
LGA infants may experience difficulties during birth. Infants of mothers with diabetes are often LGA and may have metabolic abnormalities shortly after birth, as well as congenital anomalies
a
A common complication among LGA
newborns is hypoglycemia, which can
result in jitteriness, irritability, cyanosis,
or other health issues
a
While no etiology is noted for many SGA infants, known causes include fetal, placental, and maternal factors. Maternal smoking is associated with SGA newborns
a
Preterm AGA infants are more prone to:
Preterm SGA infants are more likely to
experience:
respiratory distress syndrome, apnea,
patent ductus arteriosus (PDA) with
left-to-right shunt, and infection
asphyxia, hypoglycemia, and hypocalcemia
In breech babies (buttock first), the
knees are flexed in utero; in a frank
breech baby, the knees are extended
in utero. In both, the hips are flexed
a
By 4 days after birth, tremors at rest
signal central nervous system disease
from various possible causes, ranging
from asphyxia to drug withdrawal
a
Asymmetric movements of the arms
or legs at any time suggest central or
peripheral neurologic deficits, birth injury
(such as a fractured clavicle or brachial
plexus injury), or congenital anomalies
a
Newborns who do not demonstrate
these behaviors may have a neurologic
condition, drug withdrawal, or a
serious illness such as infection
a
If you cannot distract the infant or
engage the awake infant with an
object, your face, or a sound, consider
a possible visual or hearing deficit
a
Many neurologic conditions can be diagnosed during this general part of the examination. For example, you can detect hypotonia, conditions associated with irritability or signs of cerebral palsy (see neurologic examination below
a
Observation of the infant’s communication with the parent can reveal abnormalities such as developmental delay, language delay, hearing deficits, or inadequate parental attachment. Likewise, such observations may identify maladaptive nurturing patterns that may stem from maternal depression or inadequate social support.
a
Many disorders cause delays in more than one milestone. For most children with developmental delay, the causes are unknown. Some known causes include abnormality in embryonic development (e.g., prenatal insult); hereditary and genetic disorders (e.g., inborn errors, genetic abnormalities); environmental and social problems (e.g., insufficient stimulation); pregnancy or perinatal problems (e.g., placental insufficiency, prematurity); and childhood diseases (e.g., infection, trauma, chronic illness).
a
If a cooperative infant fails items on a standardized screening instrument, developmental delay is possible, necessitating more precise testing and evaluation.
a
An infant or toddler who has developmental
skills that plateau or are out of
sequence may have autism or cerebral
palsy.
a
As an example, an infant who was born
8 weeks prematurely at 32-week gestation
will have abnormal findings on developmental
screening if expected milestones
are not adjusted for prematurity. At a visit
at 12 months of age, the infant should be
expected to have attained milestones
appropriate for a 10-month old
a
Variations beyond two standard deviations
for age or above the 95th percentile
or below the 5th percentile are
indications for more detailed evaluation.
These deviations may be the first
and only indicators of disease (see
examples on the website tables
a
Although many healthy infants cross percentiles on growth charts, a sudden or significant change in growth may indicate systemic disease due to various possible organ systems or inappropriate excess weight gain usually due to overfeeding
a
Abnormalities that can cause deviation from normal growth patterns include chronic disease or prematurity. Growth charts are also available for children with specific conditions such as Down syndrome or Turner syndrome
a
Reduced growth velocity, shown by a drop in height percentile on a growth curve, may signify a chronic condition. Comparison with normal standards is essential because growth velocity is normally less during the second year than during the first year.
a
Chronic conditions causing reduced length or height include neurologic, renal, cardiac, gastrointestinal, and endocrine disorders as well as cystic fibrosis
a
Failure to thrive is inadequate weight gain for age. Common indicators are: (a) growth <5th percentile for age; (b) drop >2 quartiles in 6 months; or (c) weight for length <5th percentile. Causes include environmental or psychosocial factors and a variety of gastrointestinal, neurologic, cardiac, endocrine, renal, and other diseases.
a
A small head size may result from
premature closure of the sutures or
microcephaly, which may be familial
or due to chromosomal abnormalities,
congenital infections, maternal metabolic disorders, and neurologic insults
An abnormally large head size (>95th
percentile or 2 standard deviations
above the mean) is
macrocephaly which may result from: hydrocephalus, subdural hematoma brain tumor inherited syndromes
Familial megaloencephaly (large head) is a benign familial condition
Causes of sustained hypertension in newborns include renal artery disease (stenosis, thrombosis), congenital renal malformations, and coarctation of the aorta
a
While sinus tachycardia may be extremely rapid, a pulse rate that is too rapid to count (usually >180/min) may indicate paroxysmal supraventricular tachycardia (PSVT
a
Bradycardia may be from drug ingestion,
hypoxia, intracranial or neurologic
conditions, or, rarely, cardiac
dysrhythmia such as heart blockage.
a
Extremely rapid and shallow respiratory
rates are seen in newborns with
cyanotic cardiac disease and right-toleft
shunting, and metabolic acidosis.
a
Fever can raise respiratory rates in
infants by up to 10 respirations per
minute for each degree centigrade
of fever
s
Tachypnea and increased respiratory
effort in an infant are signs of lower
respiratory disease such as bronchiolitis
or pneumonia
a
Fever (>38°C or >100.4°F) in infants younger than age 2 to 3 months may be a sign of serious infection or disease. These infants should be evaluated promptly and thoroughly.
a
Potentially sick febrile infants under 3 months of age may have serious bacterial infection and should have temperatures assessed using a rectal thermometer
a
Anxiety may elevate the body temperature
of children. Excessive bundling of
infants may elevate skin temperature
but not core temperature
a
Temperature instability in a newborn may result from sepsis, metabolic abnormality, or other serious conditions. Older infants rarely manifest temperature instability
a
Some newborns with polycythemia
have a “ruddy” complexion. This is a
reddish purple color
a
Cutis marmorata is prominent in premature infants and in infants with congenital hypothyroidism and Down syndrome. If acrocyanosis does not disappear within 8 hours or with warming, cyanotic congenital heart disease should be considered
a
Central cyanosis in a baby or child of any age should raise suspicion of congenital heart disease. The best area to look for central cyanosis is the tongue and oral mucosa, not the nail beds, lips, or the extremities.
a
Pigmented light-brown lesions (<1 to 2 cm at birth) are café-au-lait spots. Isolated lesions have no significance, but multiple lesions with sharp borders may suggest neurofibromatosis
a
Skin desquamation is normal in fullterm
newborns but may rarely be a
sign of placental circulatory insufficiency
or congenital ichthyosis
a
Both erythema toxicum and pustular
melanosis may appear similar to
the pathologic vesiculopustular rash of herpes simplex or Staphylococcus
aureus skin infection
Midline hair tufts over the lumbosacral
spine region suggest a possible
spinal cord defect
a
Jaundice within the first 24 hours of
birth may be from hemolytic disease of
the newborn
a
Late-appearing jaundice or jaundice
that persists beyond 2 to 3 weeks
should raise suspicions of biliary
obstruction or liver disease
a
A common source of jaundice during the first couple of weeks is breastfeeding jaundice, which resolves around 10 to 14 days of life. Persistent jaundice requires evaluation
a
unilateral dark, purplish lesion, or “port wine stain” over the distribution of the ophthalmic branch of the trigeminal nerve may be a sign of Sturge–Weber syndrome, which is associated with seizures, hemiparesis, glaucoma, and mental retardation
a
Significant edema of the hands and feet of a newborn girl may be suggestive of Turner syndrome. Other features such as a webbed neck would reinforce this diagnosis
a
Dehydration is a common problem in
infants. Usual causes are insufficient
intake or excess loss of fluids from
diarrhea
a
An enlarged posterior fontanelle may be
present in congenital hypothyroidism.
a
Overlap of the cranial bones at the
sutures at birth, called molding, results
from passage of the head through the
birth canal; it disappears within 2 days
a
A bulging, tense fontanelle is observed in infants with increased intracranial pressure, which may be caused by central nervous system infections, neoplastic disease, or hydrocephalus (obstruction of the circulation of cerebrospinal fluid within the ventricles of the brain) (see Table 18-5, Abnormalities of the Head, p. 913
a
Early closure of the fontanelles can be
due to developing microcephaly or to
craniosynostosis or some metabolic
abnormalities
a
Delayed closure of the fontanelles is usually a normal variant, but can be due to hypothyroidism, megalocephaly, increased intracranial pressure, or rickets
a
A depressed anterior fontanelle may
be a sign of dehydration.
a
Dilated scalp veins are indicative of longstanding
increased intracranial pressure
a
A common type of localized swelling of the scalp is a cephalohematoma, caused by subperiosteal hemorrhage from the trauma of birth. This swelling does not cross over suture lines and resolves within 3 weeks. As the hemorrhage resolves and calcifies, there may be a palpable bony rim with a soft center (see Table 18-5, Abnormalities of the Head, p. 913).
a
Plagiocephaly may also reflect pathology such as torticollis from injury to the sternocleidomastoid muscle at birth or lack of stimulation of the infant.
a
Premature closure of cranial sutures causes craniosynostosis (p. 913) and an abnormally shaped skull. Sagittal suture synostosis causes a narrow head from lack of growth of the parietal bones
a
In craniotabes, the cranial bones feel springy. Craniotabes can result from increased intracranial pressure, as with hydrocephaly, metabolic disturbances such as rickets, and infection such as congenital syphilis
a
Micrognathia may also be part of a
syndrome, such as the Pierre Robin
syndrome.
a
Most developmental and genetic
syndromes with abnormal facies also
have other abnormalities
a
An infant with congenital hyperthyroidism may have coarse facial features and other abnormal facial features (Table 18-6, Diagnostic Facies in Infancy and Childhood, pp. 914–915).
a
A child with abnormal shape or length of palpebral fissures (see Table 18-6, Diagnostic Facies in Infancy and Childhood, pp. 914–915): Upslanting (Down syndrome) Downslanting (Noonan syndrome) Short (fetal alcohol effects)
a
A positive Chvostek sign produces facial grimacing caused by repeated contractions of the facial muscles. A Chvostek’s sign is noted in cases of hypocalcemic tetany, tetanus, and tetany due to hyperventilation.
a
A newborn who truly cannot open an
eye (even when awake and alert) may
have:
Causes include:
congenital ptosis
birth trauma
CN III palsy
Subconjunctival hemorrhages are
common in neonates born via vaginal
delivery
a
Nystagmus (wandering or shaking eye movements) persisting after a few days or persisting after the maneuver described on the left may indicate poor vision or central nervous system disease
m
If a newborn fails to gaze at you and follow your face during alert periods, pay particular attention to the rest of the ocular examination. The newborn may have visual impairment from congenital cataracts or other disorders
m
Alternating convergent or divergent strabismus persisting beyond 3 months, or persistent strabismus of any type, may indicate ocular motor weakness or another abnormality in the visual system
m
Colobomas may be seen with the
naked eye and represent defects in
the iris.
m
Brushfield spots (seen with an ophthalmoscope) are a ring of white specks in the iris (see Table 18-7, Abnormalities of the Eyes, Ears, and Mouth, p. 916). Although sometimes present in normal children, these strongly suggest Down syndrome
m
Persistent ocular discharge and tearing
beginning at birth may be from
dacryocystitis or nasolacrimal duct
obstruction
m
Failure to progress along these visual
developmental milestones may indicate
delayed visual maturation
a
Congenital glaucoma may cause cloudiness of the cornea. A dark light reflex can result from cataracts, retinopathy of prematurity, or other disorders. A white retinal reflex (leukokoria) is abnormal, and cataract, retinal detachment, chorioretinitis, or retinoblastoma should be suspected
m
Occlusion of the lens may represent a
cataract
m
Small retinal hemorrhages may occur in normal newborns. Extensive hemorrhages may suggest severe anoxia, subdural hematoma, subarachnoid hemorrhage, or trauma
m
Small, deformed, or low-set auricles
may indicate associated congenital
defects, especially renal disease.
m
Otitis media (see pp. 869–870) can occur in infants.
m
Perinatal problems raising the risk for hearing defects include birth weight <1,500 g, anoxia, treatment with potentially ototoxic medications, congenital infections, severe hyperbilirubinemia, and meningitis
m
In the absence of universal hearing
screening, many children with hearing
deficits are not diagnosed until 2 years.
Clues to hearing deficits include parental
concern about hearing, delayed
speech, and lack of developmental
indicators of hearing.
m
The nasal passages in newborns may be obstructed in choanal atresia. In severe cases, nasal obstruction can be assessed by attempting to pass a no. 8 feeding tube through each nostril into the posterior pharynx. This is usually done in the delivery room to assess for choanal atresia
m
Rarely, supernumerary teeth are noted.
These are usually dysmorphic and are
shed within days but are removed to
prevent aspiration.
pg.827
Although unusual, a prominent, protruding
tongue may signal congenital
hypothyroidism or Down syndrome
a
Oral candidiasis (thrush) is common in infants. The white plaques are difficult to wipe away and have an erythematous raw base (see Table 18-7, Abnormalities of the Eyes, Ears, and Mouth, p. 916). They are found on the buccal mucosa, palate, and tongue.
a
Natal teeth are teeth that are present
at birth. They are usually simply early
eruptions of normal teeth, but they
can be part of syndromes
a
Macroglossia is associated with several systemic conditions. If associated with hypoglycemia and omphalocele, the diagnosis is likely Beckwith–Wiedemann syndrome.
a
A congenital fissure of the median
line of the palate is a cleft palate
a
Inspiratory stridor beginning at birth suggests a congenital abnormality as described in this table. Stridor that appears following birth can be due to infections such as croup, a foreign body, or gastroesophageal reflux
a
Branchial cleft cysts appear as small dimples or openings anterior to the midportion of the sternocleidomastoid muscle. They may be associated with a sinus tract.
a
Preauricular cysts and sinuses are common,
pinhole-size pits, usually located
anterior to the helix of the ear. They
are often bilateral and may be associated
with hearing deficits and renal
disorders
a
Thyroglossal duct cysts are located at the midline of the neck, just above the thyroid cartilage. These small, firm, mobile masses move upward with tongue protrusion or with swallowing. They are usually detected after 2 years
a
Congenital torticollis, or a “wry neck,”
is from
bleeding into the sternocleidomastoid muscle during the stretching process during delivery. A firm fibrous mass is felt within the muscle 2 to 3 weeks after birth and generally disappears over months
A fracture of the clavicle may occur during
birth, particularly during delivery of
a difficult arm or shoulder extraction
a
Two types of chest wall abnormalities
noted in childhood include
pectus excavatum “funnel chest,”
pectus carinatum “chicken breast deformity.”
Apnea is cessation of breathing for more than 20 seconds. It is often accompanied by bradycardia and may indicate respiratory disease, central nervous system disease, or, rarely, a cardiopulmonary condition. Apnea may be a high-risk factor for SIDS
a
In newborns and young infants, nasal flaring may be the result of upper respiratory infections, with subsequent obstruction of their small nares, but it may also be caused by pneumonia or other serious respiratory infections
a
Lower respiratory infections, defined
as infections below the vocal cords,
are common in infants and include
bronchiolitis and pneumonia.
a
Acute stridor is a potentially serious
condition; causes include
laryngotracheobronchitis
(croup), epiglottitis,
bacterial tracheitis, foreign body, hemangioma,
or a vascular ring
In infants, abnormal work of breathing plus abnormal findings on auscultation are the best findings for ruling in pneumonia. The best sign for ruling out pneumonia is the absence of tachypnea
a
Asymmetric chest movement may
indicate a space-occupying lesion
a
Airway obstruction or lower respiratory tract disease in infants can result in the Hoover sign, or paradoxical (seesaw) breathing in which the abdomen moves outward while the chest moves inward during inspiration.
a
Children with muscle weakness may
be noted to have thoracoabdominal
paradox at several years of age.
a
Because of the excellent transmission of sounds throughout the chest, any abnormalities of tactile fremitus or on percussion suggest severe pathology, such as a large pneumonic consolidation.
a
Biphasic sounds imply severe obstruction
from intrathoracic airway narrowing
or severe obstruction from
extrathoracic airway narrowing
a
Diminished breath sounds in one side
of the chest of a newborn suggest
unilateral lesions (e.g., congenital diaphragmatic
hernia or pneumothorax).
a
Upper respiratory infections are not
serious in infants but can produce
loud inspiratory sounds that are often
transmitted to the chest.
a
Wheezes in infants occur commonly from asthma or bronchiolitis. Rhonchi in infants occur with upper respiratory infections. Crackles (rales) can be heard with pneumonia and bronchiolitis.
a
Central cyanosis without acute respiratory symptoms suggests cardiac disease. See Table 18-9, Cyanosis in Children, p. 918, and Table 18-10, Congenital Heart Murmurs, pp. 919–920.
a
In general, cardiac causes of central
cyanosis involve right-to-left shunting
and can be caused by a variety of
congenital cardiac lesions
a
The combination of tachypnea, tachycardia,
and hepatomegaly in infants
suggests heart failure.
A
A diffuse bulge outward of the left
side of the chest suggests longstanding
cardiomegaly
a
A “rolling” heave at the left sternal border suggests an increase in right ventricular work, whereas the same kind of motion closer to the apex suggests the same thing for the left ventricle.
a
PDA is associated with hyperdynamic
precordium and bounding distal
pulses
a
Visible and palpable chest pulsations suggest a hyperdynamic state from either increased metabolic rate or inefficient pumping as a result of an underlying cardiac defect
a
The absence or diminution of femoral pulses is indicative of coarctation of the aorta. If you cannot detect femoral pulses, measure blood pressures of one of the lower and both upper extremities. Normally, the blood pressure in the lower extremity is slightly higher than in the upper extremities. If they are equal or lower in the leg, coarctation is likely to be present.
a
A weak or thready, difficult-to-feel pulse may reflect myocardial dysfunction and heart failure, particularly if associated with an unusual degree of tachycardia
a
Although the pulses in the feet of neonates
and infants are often faint, several
conditions can cause full pulses,
such as PDA or truncus arteriosus
a
The most common abnormal dysrhythmia in infants is paroxysmal atrial tachycardia (PAT). It can occur at any age, including in utero. It is remarkably well tolerated by some infants and children and is found on examination. The child may look perfectly healthy or may be mildly pale or with tachypnea. The heart rate is sustained and regular at around 240 beats per minute or more. Some children, particularly neonates, may appear very ill. In older children, this dysrhythmia is more likely to be truly paroxysmal, with episodes of varying duration and frequency.
a
Distant heart tones suggest pericardial
effusion; mushy, less distinct heart
sounds suggest myocardial dysfunction
a
Pathologic arrhythmias in children can be from structural cardiac lesions but also from other causes such as drug ingestion, metabolic abnormalities, endocrine disorders, serious infections, and postinfectious states, or conduction disturbances without structural heart disease
a
Although ventricular premature contractions
generally occur in otherwise
healthy infants, they can occur with
underlying cardiac disease, particularly
cardiomyopathies and congenital heart
disorders. Electrolyte or metabolic disturbances
are also causes
a
A louder-than-normal pulmonic component,
particularly when louder than
the aortic sound, suggests pulmonary
hypertension
a
Persistent splitting of S2 may indicate a right ventricular volume load such as atrial septal defect, anomalies of pulmonary venous return, or chronic anemia.
a
The third heart sound (S3) should be
differentiated from the higher-intensity
third heart sound gallop, which is a
sign of underlying pathology.
a
Fourth heart sounds (S4), not often
heard in children, are low-frequency,
late diastolic sounds, occurring just
before the first heart sound
a
A true gallop rhythm (in contrast to a widely split S2 which gives an apparent gallop)—tachycardia plus a loud S3, S4, or both—is pathologic and indicates heart failure (poor ventricular function).
a
Any of the noncardiac findings that
frequently accompany cardiac disease
in children markedly raises the possibility
that a murmur is pathologic.
a
Some pathologic murmurs of congenital heart disease are present at birth. Others are not apparent until later, depending on their severity, drop in pulmonary vascular resistance following birth, or changes associated with growth of the child. Table 18-10, Congenital Heart Murmurs, on pp. 919–920, shows examples of pathologic murmurs of childhood.
a
A pulmonary flow murmur in the newborn with other signs of disease is more likely to be pathologic. Diseases may include Williams syndrome, congenital rubella syndrome, and Alagille syndrome
a
