Case 2 (Asia): WCC at 2, 6, 9 months with neuroblastoma Flashcards
Well-infant visit: Interval history
Any illnesses or problems since the previous visit (if it is the initial visit, include a birth history [details of pregnancy and delivery: illness, medication, substance use, problems with delivery, prenatal labwork, results of newborn hearing screen])
Well-infant visit: Growth assessment
Head circumference, weight, and length/height
Best assessed using a growth chart and analyzing the data over time
Babies lose a little weight right after birth, but are expected to be back at a weight >= their birth weight by 2 weeks of age
Average daily weight gain for a term infant is 20–30 grams.
Weight (approximation):
- Weight at 4 or 5 months=double birth weight
- Weight at 12 months=triple birth weight
Length (approximation):
- Length at 48 months=double birth length
Well-infant visit: Development assessment
At each well visit, physician should assess the four domains of development: Gross motor, fine motor, language/communication and social/behavior.
If child is unable to achieve the milestones in one or any of the four areas at or near the appropriate age, then these areas are of concern for possible delay and further testing or evaluation should be done.
Developmental surveillance:
- Comparing a child to expected behaviors by age
- Not as sensitive or specific as developmental screening using a validated tool
Developmental screening:
- Assessment using an evidence-based developmental screening tool to pick up
developmental or behavioral abnormalities. An example is the Parents’Evaluation of Developmental Status (PEDS) for children birth to 8 years
- May take place routinely during well-child visit or at any patient encounter where there are concerns.
Well-infant visit: Diet assessment
Breastfeeding or taking formula (if formula, how is it being prepared)
Vitamin D supplementation
Quantity and timing of feeds
Number of wet and soiled diapers per day
Well-infant visit: Social history
Who lives with child; who are child’s caregivers
Well-infant visit: Anticipatory guidance
A chance to help the parents anticipate child’s development and nutritional needs and to advise them regarding child’s safety. Topics may include:
Child care
Sleep patterns:
- To prevent sudden infant death syndrome (SIDS), infants must sleep on their backs.
- Most babies sleep through night by age 4 to 6 months.
- Infants at 6 months of age usually sleep through the night and take two naps during the day.
Exposure to tobacco smoke
Childproofing the home:
- Outlet covers, cabinet locks, stair barriers
- Safe storage of cleaning supplies and medicines
- Poison control number; place near phone
Use of walkers:
- These are not recommended due to risk of injury, especially when there are stairs in home.
Car seat safety:
- Infants should be placed, facing the rear, in the middle of the back seat, since that is the most protected part of the automobile.
- Children < 13 years should not sit in the front seat. The back seat is the safest place.
- 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.
Well-infant visit: Immunizations (in first 5 years; combo vaccines; influenza immunization recs; side-effects)
Within the first five years of life, every child should receive the following vaccines (total number of each):
- DTaP: Diphtheria, tetanus, and acellular pertussis (5)
- IPV: Inactivated polio vaccine (4)
- Hib: Haemophilus influenza Type b (3 or 4, depending on manufacturer)
- PCV13: Pneumococcal conjugate vaccine, 13 serotypes (4)
- MMR: Measles, mumps, and rubella (2)
- Varicella (2)
- RotaV: Rotavirus (2 or 3, depending on manufacturer)
- HepA: Hepatitis A (2)
- HepB: Hepatitis B (3)
Combination vaccines may be used instead of their equivalent component vaccines if licensed and indicated for the patient’s age, (e.g., Pediarix®—which combines the
immunizations for DTaP, HepB, and IPV—and Pentacel®—which combines the DTaP, IPV, and Hib).
Annual influenza immunization recommendations:
- All children 6 months through 19 years of age
- Household contacts and out-of-home caregivers of children 0 to 59 months of age
- Children and adolescents in high-risk groups (e.g., asthma, lung or heart disorders, and immune deficiencies) are higher priority.
Common immunization side effects: Fussiness and fever for 24 hours. If these persist for >24 hours, or more serious side effects, child should be seen right away.
Infant nutrition: Until 4-6 months…; water recs
Until age 4–6 months, infants should be given only breast milk or formula.
Plain water should not be given for hydration until infant is eating solid foods.
Infant nutrition: Breast milk recs
Preferred source of nutrition
Infant nutrition: Commercial formulas
Protein sources: Cow-milk protein, soy protein or hydrolyzed cow’s milk protein. Elemental formulas provide protein in the form of simple amino acids.
Regular cow’s milk not given until age 12 months due to concern for colitis
Formula types: Ready-to-feed (RTF) or those that require mixing prior to feeding (power or formula concentrate). Advise parents to follow package directions carefully when using powder or concentrate, and never to dilute
formula.
- RTF: Given directly to infant from bottle without preparation
- Powder: 2 scoops powder mixed in 4 oz. (1/2 cup) water
- Concentrate: A 1:1 ratio of concentrate to water
Infant nutrition: Caloric requirements of infant
Term infants: 100–120 calories/kilogram (kg)/day
Preterm infants: 115–130 calories/kg/day
Very low birth weight (VLBW) infants: Up to 150 calories/kg/day
Infant nutrition: Vitamin D supplementation recs
Breastfeeding infants need vitamin D supplementation (formula and milk are already supplemented).
Most cost-effective method is with a multivitamin.
Infant nutrition: Transition to solid foods
Typically occurs at ages 4–6 months (for infants born
prematurely, use adjusted age):
Many infants will not be ready for solid foods at 4 months.
Signs that child is ready for solid foods:
- Able to sit up and keep head up on his/her own
- Can manipulate pureed foods like rice cereal in mouth (will not spit it out)
- Shows interest in solid foods (e.g., will open mouth and does not refuse spoon). Start by offering a small amount of iron-fortified infant rice cereal mixed with formula and watch how child accepts it, if at all.
- Each new food should be introduced only every five to seven days so that allergies can be identified.
Feeding of 9-month-old infant: Requires 100 calories/kg/day, with approximately 75% of calories from breast milk or formula (i.e., 24–28 oz per day)
Can eat strained foods (Stage 2)—which require more chewing—and feed themselves with finger foods, such as toast, crackers, pasta, and banana.
Meats, such as small pieces of chicken, may be started at this age.
Discuss choking hazards with parents. Foods such as popcorn, grapes, hard candies, hot dogs, and jelly candies should never be offered at this age.
Developmental Milestones: 2 months
Gross motor:
- lifts head
- head up 45 degrees
Fine motor:
- follows to or past midline
Language/Cognitive:
- vocalizes
Social/Personal:
- smiles responsively
- smiles spontaneously
Developmental Milestones: 4 months
Gross motor:
- sits with head steady
- rolls over
Fine motor:
- follows 180 degrees
- grasps rattle
Language/Cognitive:
- laughs
- turns to rattle sound
Social/Personal:
- regards own hand
