2: Infant female well-child visits (2, 6, and 9 months)

Question 1

Components of a Well Child Visit: Interval History

Answer 1

-Ask if there have been any illnesses or problems since the previous visit. -If this is the first visit, obtain a detailed birth hx.

Question 2

Components of a Well Child Visit: Development

Answer 2

-May be assessed using one of several developmental screening tests (e.g., the Parents’ Evaluation of Developmental Status (PEDS), or Ages and Stages Questionnaire (ASQ).-AAP mandates developmental screening at the 9mo, 18mo, and 30mo checkups.-Specific autism screening is recommended at 18 mo- old and 2yo.-Many offices do developmental screening at every health maintenance visit, especially if the office takes care of children who have been medically underserved.-Tests may involve parental reports and/or examination in the office.

Question 3

Components of a Well Child Visit: Growth

Answer 3

Growth is best assessed using a growth chart and analyzing the data over time.

Question 4

Components of a Well Child Visit: Diet Hx

Answer 4

feeding practices: breast or bottle (if an infant), or (if older child) type of food and drink, frequency, and any difficulties the parent has noted with feeding.

Question 5

Components of a Well Child Visit: Social Hx

Answer 5

-who lives with the child and who the primary caretakers are. -assess for environmental risks (e.g., smokers, guns in the home, lead exposure).

Question 6

Components of a Well Child Visit: PE

Answer 6

thoroughly conduct one

Question 7

Components of a Well Child Visit: Anticipatory Guidance

Answer 7

help the parents anticipate the child’s development and nutritional needs and to advise them regarding the child’s safety

Question 8

Components of a Well Child Visit: Immunizations and labwork

Answer 8

The visit is concluded by immunizations or screening labs, if warranted at that particular age.

Question 9

Nutrition Guidance: Breast Milk

Answer 9

preferred source of nutrition for most babies.

Question 10

Nutrition Guidance: Formula

Answer 10

Commercial formulas provide complete nutrition for those babies whose mothers are unable or unwilling to breastfeed. Available formulas include those made with:–Cow’s milk protein–Soy protein, or–Hydrolyzed cow’s milk proteinThere are also specialized formulas that provide protein in the form of simple AA (the true elemental formulas).

Question 11

Nutrition Guidance: Preparing the Formula

Answer 11

-Ready-to-feed formula: Baby is fed directly from the bottle-Powder: Two scoops of the powder are mixed with 4 oz water -Formula concentrate: ratio is one part concentrate to one part water

Question 12

Nutrition Guidance: Transition to Regular Cow’s Milk

Answer 12

Infants should take breast milk or formula until 12mo. A/c to AAP:–Young infants cannot digest cow’s milk as completely or easily as they digest breast milk or formula. –Cow’s milk contains high concentrations of protein and minerals, which can stress a newborn’s immature kidneys.–Cow’s milk lacks iron, vitamin C, and other nutrients that infants need.–It can also irritate the lining of the stomach and intestine, leading to blood loss in the stool.–Cow’s milk does not contain the optimal types of fat for growing infants.

Question 13

Early Growth

Answer 13

Most babies lose a little weight right after birth, then may regain their birth weight as early as 1 wk, but are definitely expected to have regained their birth weight by 2 wk.

Question 14

Caloric Requirements of 1- to 2-Month-Olds: term infant

Answer 14

Adequate growth for a term infant requires approximately 100 to 120 cal/kg/day. Average daily weight gain for a term infant is 20 to 30 grams.

Question 15

Caloric Requirements of 1- to 2-Month-Olds: preterm infant

Answer 15

require 115 to 130 cal/kg/day.

Question 16

Caloric Requirements of 1- to 2-Month-Olds: VLBW infants

Answer 16

require up to 150 cal/kg/day

Question 17

Moro Reflex

Answer 17

-elicited by an abrupt change in the infant’s head position and consists of two parts:–Symmetric abduction–Extension of the arms followed by adduction of the arms, sometimes with a cry.–present at birth, disappears by 4 mo.–may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries.

Question 18

Developmental surveillance generally includes assessment of milestones in four domains

Answer 18

-Gross motor-Fine motor-Communication/social-Cognitive/adaptive

Question 19

Screening with a validated tool is recommended at what ages

Answer 19

9, 18, and 24 months of age

Question 20

Anticipatory Guidance at the 2-month Visit: Solid Foods

Answer 20

Some infants may be started on rice cereal with a spoon at age 4 months.

Question 21

Anticipatory Guidance at the 2-month Visit: Vit D

Answer 21

-AAP recommended daily allowance for vitamin D is 400 units per day-Infants and children who are exclusively or mostly breastfed should be supplemented, as should infants and children drinking < a quart/day of formula or cows milk.-Infants:liquid vitamin drops; older children:chewable multivitamins.

Question 22

Anticipatory Guidance at the 2-month Visit: Child Care

Answer 22

choose a child care center

Question 23

Anticipatory Guidance at the 2-month Visit: Sleep

Answer 23

-Most babies sleep through the night by age 4 to 6 months.-To help prevent SIDS, an infant should continue to be placed on her back to go to sleep.

Question 24

Anticipatory Guidance at the 2-month Visit: Safety

Answer 24

-Family members who smoke should be advised to quit or, at the very least, should avoid smoking around the infant.-Keep small objects and plastic bags away from the baby.-Do not drink hot liquids while holding the baby.-Do not leave the infant alone on high places like the sofa or changing table. Always keep a hand on these squiggly babies!

Question 25

Car Seat Safety

Answer 25

-Kids <13y should not sit in the front seat.-Until age 2yo, children should face rearward.-The middle of the back is the most protected part of the automobile.-Car seats for children are required by law in all 50 states. -Proper use is essential for optimum performance. -The most effective car-seat restraint is a five-point harness, consisting of two shoulder straps, a lap belt and a crotch strap.

Question 26

DTap

Answer 26

immunizes against: Diphtheria, tetanus, pertussis; 5 doses

Question 27

IPV

Answer 27

imm vs. polio; 4 doses

Question 28

Hib

Answer 28

Imm vs. HIb; 3 or 4 doses

Question 29

PCV13

Answer 29

imm vs. Pneumococcus (13 strains); 4 doses

Question 30

MMR

Answer 30

imm vs. measles, mumps, rubella; 2 doses

Question 31

Varicella

Answer 31

imm vs. varicella; 2 doses

Question 32

RotaV

Answer 32

imm vs Rotavirus; 2 or 3 doses

Question 33

Hep A

Answer 33

2 doses

Question 34

Hep B

Answer 34

3 doses

Question 35

Seasonal Influenza

Answer 35

-annual influenza immunization is strongly recommended for all children 6-59 mo since they are at highest risk. -also strongly recommended for household contacts and out-of-home caregivers of children 0-59 mo and for children and adolescents in high-risk groups, (pts w/ asthma, or other lung, heart, or immune system problems.)-The vaccine is also routinely recommended for all children under age 19 years.

Question 36

Vaccine Adverse Events

Answer 36

-“knots” in the skin at the injection site (which may persist for a few weeks) -fussiness and fever for 24 hours.<24 hrs or there are more serious side effects-such as seizures or inconsolability-the child should be evaluated right away»

Question 37

Typical Early Childhood Growth Patterns

Answer 37

Most healthy infants will:-double their birth weight by 4-5 mo-triple their birth weight by 1 year of age. –In addition, most children will reach double their birth length by age 4 years.

Question 38

The Red Reflex

Answer 38

-red or orange color reflected from the fundus through the pupil when viewed through an ophthalmoscope approx 10 inches from the pt.-It gives direct info about the clarity of the eye structures and therefore is a substitute for a careful fundoscopic exam-should be elicited in all infants and children beginning at birth

Question 39

Absence of a red reflex may indicate underlying abnormalities, including:

Answer 39

-Cataracts -Glaucoma -Retinoblastoma -Chorioretinitis

Question 40

Toddler-Proofing the Home

Answer 40

-Installing outlet covers-Putting in cabinet locks-Setting up stair barriers and-Making sure cleaning supplies and medicines are safely stored.

Question 41

Anticipatory Guidance at the 6-month Visit: Car Seat Placement

Answer 41

The car seat should still be in the back seat, facing the rear.

Question 42

Anticipatory Guidance at the 6-month Visit: Use of walkers

Answer 42

AAP has recommended against the use of walkers because of the risk of injury, especially when there are stairs in the home. In addition, walkers do not teach children to walk any earlier than they otherwise would.

Question 43

Anticipatory Guidance at the 6-month Visit: Dietary Changes

Answer 43

New foods may be added to the diet every 5 to 7 days.

Question 44

Anticipatory Guidance at the 6-month Visit: Developmental changes

Answer 44

-6-mo may be resistant to being away from their primary caretaker for the next few mo, but this “stranger anxiety” is normal.-If not already begun, now is a great time to start reading books to the infant.-6mo should be expected to take two naps per day, and will probably sleep through the night.

Question 45

Acetaminophen and Vaccines

Answer 45

Use of acetaminophen may cause a lower antibody response for some immunizations. It should be administered only if absolutely necessary.

Question 46

12 Month Developmental Milestones

Answer 46

-Gross motor: Stands alone (many can walk well).-Fine motor: Has a well developed, “neat” pincer grasp.-Language: Says “mama” and “dada” (specific) and one or two other words.-Social/adaptive: Hands parent a book to read, points when wants something, imitates activities and plays ball with examiner.

Question 47

Prognosis of Stage 4S Neuroblastoma

Answer 47

-It seems paradoxical for a ca that has mets to be considered a favorable stage. However, in infants <1yo, these tumors may spontaneously regress.-This is due to the unique nature of this tumor derived from embryonal cell lines.

Question 48

Genetics of Neuroblastoma (Familial)

Answer 48

1% of cases. The familial form appears to be autosomal dominant, with low penetrance.

Question 49

Genetics of Neuroblastoma (NON-familial)

Answer 49

somatic mutations; arise in cells other than the gametes. Somatic mutations are not passed to the next generation

Question 50

Growth Parameters

Answer 50

-weight and length-head circumference (Measure the circumference around the widest portion of the head, from the occipital to the frontal area.)-growth chart

Question 51

Initial workup for abdominal mass: CBC with Differential

Answer 51

-CBC w/ differential is helpful in identifying the extent of anemia and to look for cytopenia that may be associated with bone marrow infiltration.-This test is not specific for any one diagnosis.

Question 52

Initial workup for abdominal mass: Catecholamine Metabolites (VMA and HVA)

Answer 52

-Urine or serum VMA/HVA measures metabolites of catecholamines, which are elevated in neuroblastoma.-This test is highly specific for neuroblastoma and can be 90-95% sensitive in its detection

Question 53

Initial workup for abdominal mass: Chest X-ray

Answer 53

-A chest x-ray can identify metastases to the chest.-Chest CT or MRI is necessary only if metastases are seen on x-ray.

Question 54

Initial workup for abdominal mass: Skeletal Survey

Answer 54

can identify metastases to the bone.

Question 55

Initial workup for abdominal mass: Abdominal US

Answer 55

-will identify a mass, show the organ of origin, and determine if the mass is solid, cystic or combined. (Purely cystic masses are less likely to be malignant.)-This is the best choice for a first imaging study.

Question 56

Initial workup for abdominal mass: Abdominal X-ray

Answer 56

-A plain film can identify the presence of a mass, and perhaps whether it has calcifications, it cannot reveal other important information about the mass.-This film may be more urgent if there is any evidence of bowel obstruction from the mass.

Question 57

Initial workup for abdominal mass: Abdominal CT

Answer 57

-best at revealing calcifications, and-importantly especially for a surgeon-shows the anatomy better than an US. It also reveals the consistency of the tumor.-Allows lung eval d/r the same study, which is important in finding mets.-If a lesion is purely cystic, a CT scan is not needed, which is why an US is done first.

Question 58

Differential Diagnosis for RUQ Mass and Pallor in a 9-Month-Old Infant: Hepatic Neoplasm

Answer 58

-Although rare in children this age, an hepatic neoplasm (whether malignant, such as hepatoblastoma, or benign) can cause an asymptomatic abdominal tumor and must be considered in a young infant with an asymptomatic RUQ abdominal mass.-Jaundice may be a feature, but the lack of jaundice does not rule out this diagnosis.

Question 59

Differential Diagnosis for RUQ Mass and Pallor in a 9-Month-Old Infant: Neuroblastoma

Answer 59

-The most frequently diagnosed neoplasm in infants; more than half of patients present before age 2.-The tumor may present as a painless mass in the neck, chest, or abdomen.-Children with an abdominal neuroblastoma may be asymptomatic; however, they may also appear chronically ill and may have bone pain from metastases to the bone marrow or skeleton.-Fever, pallor, and weight loss are frequent presenting s/s.-Neuroblastoma is a likely diagnosis in an infant younger <1yo who has an asymptomatic RUQ abdominal mass and pallor and no jaundice.

Question 60

Differential Diagnosis for RUQ Mass and Pallor in a 9-Month-Old Infant: Teratoma

Answer 60

-this is a rare malignant tumor-may present as a painless abdominal mass without other s/s or it may cause pressure effects on neighboring structures resulting in abdominal or back pain, n/v, constipation, and/or urinary tract symptoms

Question 61

Differential Diagnosis for RUQ Mass and Pallor in a 9-Month-Old Infant: Hydronephrosis

Answer 61

-An obstruction at the uretero-pelvic junction can lead to hydronephrosis and a palpable kidney, sometimes manifesting as a flank mass.-In the newborn, a multicystic kidney may cause such an obstruction.-While possibly asymptomatic, hydronephrosis causing a 6 cm palpable mass would usually present with a urinary tract infection.

Question 62

Differential Diagnosis for RUQ Mass and Pallor in a 9-Month-Old Infant: Wilms’ Tumor (Nephroblastoma)

Answer 62

-This is a likely diagnosis in a child with an asymptomatic RUQ abdominal mass who has no lymphadenopathy or jaundice on exam and who is growing and developing normally.-These tumors are often discovered by the parents or on routine examination. -The masses are generally smooth and rarely cross the midline.-Associated s/s occur in 50% of pts and include abdominal pain and/or vomiting; pts may also be hypertensive.-median age at diagnosis is 3y

Question 63

Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of rhinorrhea and non-productive cough. When he was born he was large for gestational age, and his exam then was notable for macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals signs are stable. He has copious nasal discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass?

Answer 63

Wilms’ tumor (nephroblastoma) is commonly associated with Beckwith-Wiedemann syndrome, a genetic overgrowth syndrome. Other features that may be seen in children with this syndrome include omphalocele, hemihypertrophy, hypoglycemia, large for gestational age, and other dysmorphic features.

Question 64

A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis?

Answer 64

In addition to neuroblastoma, other tumors associated with small blue cells include Ewing’s sarcoma and medulloblastoma, both of which tumors are seen in children.