CLIPP case 2. Infant well-childs (neuroblastoma, food, vaccines) Flashcards
Caloric requirement of health term babies in first 2 months of life
100 cal/kg/day
115 for preterm and 150 for VLBW
Moro reflex
- Abrupt change in the infant’s head position -> symmetric abduction and extension of the arms followed by adduction of the arms, sometimes with a cry
- Disappears by 4 months
- Used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries
Normal infant rashes
Acne and seborrheic dermatitis
Primitive reflexes present at birth
Moro (4mo), palmar grasp (3mo), plantar grasp (8mo), Asymmetric tonic neck/fencing (6mo), Babinski (2yr)
Four domains of developmental milestones
Gross motor, fine motor, language, social
Gross motor milestones (90%, 50-90%)
2 months: lift head, 45 degrees
4 months: sit-head steady, roll over
6 months: roll over, sit-no support
9 months: stand holding on, pull to stand
12 months: stands alone, maybe walk
Fine motor milestones (90%, 50-90%)
2 months: follow to midline, past midline
4 months: grasp raddle, follow 180 degrees
6 months: reach, look for dropped yarn
9 months: transfer cube, take 2 cubes
12 months: neat pincer grasp
Language milestones (90%, 50-90%)
2 months: vocalize, laugh
4 months: laugh, turn to rattling sound
6 months: turn to rattling, turn to voice
9 months: single syllables, dada/mama
12 months: mama and dada specific, and 1 other word
Social-emotional (90%, 50-90%)
2 months: smile response, smile spontaneous
4 months: regard own hand
6 months: work for toy out-of-reach, feed self
9 months: feed self, wave bye
12 months: hands book to read, points when wants, imitates activities, plays ball with examiner
PEDS screening tool
- evidence-based
- used 0-8yo
- able to be performed at all well-child visits
- used to identify developmental delay and need for further w/u
When can introduce solids foods
- Rice cereal, iron-fortified, as early as 4 months
- New food every 5-7 days (to identify allergies)
- Signs of readiness: Able to sit up and keep head up on own; Can manipulate pureed foods like rice cereal in mouth (will not spit it out)
Vitamin D supplementation
Likely deficient unless drinking 1 quart (32 oz) per day (breast/formula/cows). If mostly or solely breast feeding, supplement with max 400 units per day via multivitamin.
When do they sleep through the night
By 4-6 months
Sleeping position
On back to prevent SIDS
CDC vaccination schedule
See CDC
By when should an infant double and triple its birthweight?
Double by 5 months
Triple by 12 months
Red reflex
*Red/orange color reflected from the fundus through pupil when viewed through ophthalmoscope 10 inches from the patient
*Normal if symmetric coloration and no leukocoria
*Absence of a red reflex may indicate underlying abnormalities, including:
Cataracts
Glaucoma
Retinoblastoma
Chorioretinitis
Acetaminophen and vaccines
May cause a lower antibody response, and should be administered only if absolutely necessary
Anticipatory guidance
*Sleep: Place on back to prevent SIDS. 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
*Car seat: Infants facing rear, in middle of back seat. The most effective car-seat restraint is a five-point harness. Children < 13 years should not sit in the front seat.
*Other: child care, tobacco exposure, childproof home, walkers not recommended
Rectal exam in infant
Only when intra-abdominal, pelvic, or peri-rectal process suspected
Neuroblastoma
- The most frequently diagnosed neoplasm in infants–more than half of patients present before age 2
- Presents as painless mass in the neck, chest, or abdomen
- Asymptomatic, or chronically ill with bone pain from bone marrow or skeleton mets. Fever, pallor, and weight loss are frequent presenting symptoms.
- Neuroblastoma is a likely diagnosis in an infant younger than a year of age who has an asymptomatic RUQ abdominal mass and pallor and no jaundice
- Normocytic anemia and small cell rosettes in the bone marrow
- Elevated urinary catecholamines
- Stage 4S disease carries a favorable outcome (infant <1yo)
RUQ mass in a 9 month old
DDx:
- Neuroblastoma
- Wilms’ tumor (nephroblastoma)
- Teratoma
- Hepatic tumor
- Hydronephrosis
By when should an infant double its birth length?
48 months (4yo)
Developmental surveillance versus screening
*Surveillance: Comparing a child to expected behaviors by age. Not as sensitive or specific as screening
*Screening: Assessment using evidence-based tool to pick up developmental or behavioral abnormalities. PEDS (Parents’
Evaluation of Developmental Status) for birth to 8 years. May take place routinely during well-child visit or at any patient encounter
where there are concerns.
Immunizations received by age 5
- DTaP x5
- IPV x4
- PCV13 x4
- Hib x3 or 4
- RotaV x2 or 3
- MMR x2 (age 1 and 5)
- VZV x2 (age 1 and 5)
- HepA x2 (12 and 18 months)
- HepB x3
- Annueal influenza: 6 mo - 19 yo, household contacts and caregivers, high-risk groups (asthma, lung or heart disorders, immune deficiencies). Kids < 9 years need two doses one month apart.
Immunization reaction
- Fussiness and fever for 24 hours
* If persist >24 hours, or more serious, child should be seen right away
When can you start plain water?
When infant is eating solid foods
When can you introduce cow’s milk?
12 months. No earlier due to concern for colitis
Feeding of 9 month-old infant
*Requires 100 calories/kg/day, with 75% from breast milk or formula
*Can eat strained foods (Stage 2) and feed
self with finger foods (toast, crackers, pasta, and banana)
*May start meats (small pieces chicken)
*Discuss choking hazards: no popcorn, grapes, hard candies, hot dogs, or jelly candies
Wilm’s tumor
- May present as asymptomatic RUQ abdominal mass without lymphadenopathy or jaundice, growing and developing normally. *Masses generally smooth and rarely cross midline
- Associated symptoms in 50% of patients: abdominal pain, vomiting, hypertensive
- Median age at diagnosis is 3yo
Teratoma (germ cell tumor)
- Very rare, malignant tumor, presents as painless abdominal mass with no symptoms (no jaundice, pallor)
- If there are symptoms, related to pressure effects on neighboring structures: abdominal or back pain, nausea, vomiting, constipation, and urinary tract symptoms
Hepatic tumor
- Hepatoblastoma and benign liver tumors
* Rare but consider in a young infant with asymptomatic RUQ abdominal mass. +/- jaundice
Hydronephrosis
- Obstruction at the uretero-pelvic junction -> hydronephrosis with palpable kidney -> flank mass.
- May be asymptomatic, although usually with UTI
