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N825 - Primary Care Pediatrics > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Infants ____________ are best examined on the exam table

A

Under 6 months

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2
Q

Infants ___________________ are best examined in parents’ lap due to anxiety towards strangers

A

Over 6 months

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3
Q

Pediatric visit acronym: BUDS

Address with each encounter

A

B - bowels
U - urine - more frequently than adults
D - diet - breast vs formula, introducing foods, etc
S - sleep - schedule, feeding q3h overnight to avoid hypoglycemia

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4
Q

Pediatric visit acronym: NEST

A

N - nutrition
E - elimination
S - sleep
T - Track child’s growth and health (milestones, learning, etc)

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5
Q

Pediatric Nutrition Acronym: Na.Vi.Ga.Te.D.

A

Na - Natural foods (types/quantities, fruits, vegetables, protein sources, fats)
Vi - Vitamins (evaluate for deficiencies, especially IRON sources d/t risk for dev delay)
Ga - Grains and Added sugar and salt (amount of whole grains, added salts/sugars to monitor for obesity)
Te - Teeth and gum care (fluoride, teeth brushing, prevent cardiac issues)
D - Dairy consumption (too much leads to IRON deficiency d/t it binding and not properly absorbing, leading to anemia and dev delay)

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6
Q

Elimination Clinical Pearls

A

Stool and urine elimination is a helpful indicator of health
Educate on normal vs not normal
John Hopkins Stool Color Guide Reference
Evaluate for rectal stenosis as needed

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7
Q

John Hopkins Stool Color Guide

  • Normal Breast Fed
  • Normal Formula Fed
  • Meconium
  • Abnormal w/ liver issues
  • Dairy Intolerance
A

Normal Breast Fed - mustardy, seedy d/t high level of absorption by baby
Normal Formula Fed - Darker brown/green/yellow, more chunky
Meconium - black poop for first 1-2 days after birth, ABNORMAL if persists beyond three days
Abnormal liver issues - white, pale yellow, chalky grey color (biliary atresia)
Abnormal dairy intolerance - Rectal irritation with small blood staining. Formulas including Enfamil and Similac contain dairy.

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8
Q

Sleep Clinical Pearls

A 
Inquire about:
Positioning - sleep on back
Quality/Quantity 
Sleep Routines
Sleep Safety - Avoid soft bedding, supine position, no extra pillows/blankets, use pacifier
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9
Q 
Sleep per day for:
Newborn (0-3 mo)
Infant (4-12 mo)
Toddler (1-2 yr)
Preschool (3-5 yr)
School age (6-12 yr)
Teen (13-18)
A 
Newborn - 14-17 hours
Infant - 12-16 hours
Toddler - 11-14 hours
Preschool - 10-13 hours
School age - 9-12 hours
Teen - 8-10 hours
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10
Q

PE approach for Infant, toddler, preschooler, school age, adolescent

A

Infant - lying in parent’s arms, eyes/ears/mouth at end of exam, heart/lungs when child is sleeping/quiet, distract with older infants.
Toddler - minimal contact, allow child to look at and touch equipment, heart/lungs first then head to toe.
Preschooler - Similar to toddler, especially allow child to touch equipment
School age - Respect privacy, explain steps beforehand
Adolescent - Explain findings, respect privacy

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11
Q 
Infant Vital Sign Parameters
HR
Resp
BP
Temperature
A

HR - 100-160
Resp - 30-60 for 0-6 mo; 24-30 for 6-12 mo
BP - not checked
Temperature - 98.6F

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12
Q 
Child Vital Sign Parameters 1-11 years
HR
Resp
BP
Temp
A

HR - 70-120
Resp - 20-30 for 1-5yo; 12-20 for 6-11yo
BP - 90-110/55
Temp - 98.6

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13
Q 
Teen Vital Sign Parameters
HR
Resp
BP
Temp
A

HR - 60-100
Resp - 12-18
BP - 110-135/65-85
Temp - 98.6F

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14
Q

Measurements of the Pediatric Patient

A

Growth charts for length, weight, and head circumference until 2yo
Temperature, weight, length, head circumference, HR, Resp, BP

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15
Q

Weight loss patterns - Neonates

A

Lose up to 10% body weight within the first week

Regain birth weight by 2 weeks of age (gain 20-30g per day)

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16
Q

Weight Measurement Infant (6 mo and 12 mo weight gain)

A

Infants DOUBLE their birth weight by 6 mo

Infants TRIPLE their birth weight by 12 mo

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17
Q

Growth Chart for Weight

A

5th-85th percentile is WNL

FTT if weight/height decreases by 2+ major percentiles, or if below 3-5%
- Weight decreases first, then length, then HC

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18
Q

How to obtain weight measurement

A

weigh in nude or clean diaper
Round to nearest 0.01 kg (or 1/2 oz)
Weigh twice for accuracy
Use standing scale if over 3 yo

BMI - don’t measure until 24 mo visit (results skewed prior to 2 yo)

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19
Q

WHO vs CDC Growth Charts

A

WHO - 2-98 percentile considered normal; use until 24 mo.

CDC - 5-85 percentile considered normal; use for ages 2-20

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20
Q

Measuring length/height

A

Average length is 50 cm at birth
Increases by 50% by year 1
Doubles by year 4
Triples by year 13
Increases by 1” per month during first 6 months; then by 0.5” from 6-12 mo
R/o familial short stature, constitutional delay, endocrine or bone disorders, puberty delays, etc.

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21
Q

How to measure length

A

Supine until able to stand (24 mo)
>2 yo - remove shoes
Measure x2 for accuracy
If child falls off growth chart grid, requires work-up

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22
Q

Head Circumference Growth Chart

A 
Occipital frontal circumference
Avg at birth is 35 cm
Grows by 12 cm by 12 mo
Measure each visit until 24 mo
*** HC should correlate to child's length
Microcephay - <10th percentile
Macrocephaly - >90th percentile
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23
Q

How to measure head circumference

A

Measure x2 for accuracy
Round to nearest 0.1 cm or 1/8”
Measure over largest circumference of head - occiput and above eyebrows

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24
Q

Blood Pressure Measurements

A

Start monitoring at age 3 (using appropriate cuff size)
Monitor annually unless patient has risk factors (obese, on meds that cause HTN, renal dz, DM, COA)
HTN dx after multiple measurements over time, in >95th percentile on 3 different visits.

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25
Q

2 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)

A

Social/Emotional - smile, briefly calm self, looks at parent

Language - cooing, gurgling, turning head towards sound

Cognitive - pays attention to faces, follow objects with eyes, recognizes people at a distance, acts bored if activity doesn’t change

Movement/Physical - hold head up, push up when on tummy, smoother movements with arms and legs

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26
Q

2 Month Milestone Red Flags

A 
Not responding to loud sounds
Not watching moving objects
Not smiling at people
Not bringing hands to mouth
Unable to hold up head when pushing up on tummy
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27
Q

4 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)

A

Social/Emotional - smiles spontaneously especially at people; play with people and cries when they stop; copies movements and expressions

Language/Communication - babble with expressions, copies sounds, cries in different ways (hunger, pain, tired), laughing

Cognitive - happy or sad, responds to affection, reaches for toys with hand, uses hands and eyes together, follows things with eyes, watches faces closely, recognizes familiar faces at a distance

Movement/Physical - holds head steady while unsupported (HEAD LAG IS A RED FLAG), roll from belly to back, lift head to look around when on belly, brings hands to mouth

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28
Q

4 Month Milestone Red Flags

A 
Not watching moving objects
Head lag
Not smiling at people
Not able to hold head steady
Not cooing or making sounds
Not bringing things to mouth
Not pushing down with legs when feet are on hard surface
Trouble moving one or both eyes in all directions
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29
Q

6 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)

A

Social/Emotional - knows familiar faces compared to strangers, play with others especially parents, responds to other emotions and is happy, looks at self in mirror

Language - responds to voice, strings vowels together when babbling (ah, eh, oh), takes turns with patients making sounds, responds to name, shows joy and displeasure, begins to say consonants (jabbering with M and B)

Cognitive - looking around, brings objects to mouth, curiosity towards objects out of reach and tries to get, pass things from one hand to the other.

Movement/physical - rolls in both directions, sitting without support, when standing is able to support weight on legs and maybe bounce, rocks back and forth, crawling backwards before moving forwards (number 6 looks like figure sitting)

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30
Q

6 Month Milestone Redflags

A 
Not trying to grab things within reach
No affection towards caregivers
Not responding to sound around them
Difficulty getting things to mouth
Not making vowel noises (ah, eh, oh)
No rolling over in either direction
Not laughing or making squealing sounds
Stiffness, tight muscles
Very floppy, like a rag doll
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31
Q

9 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)

A

Social/Emotional - afraid of strangers, clingy with familiar people, favorite toys

Language - understands NO, different sounds (mamamama, bababa), copies sounds/gestures of others, points with fingers

Cognitive - watches path of something as it falls, looks for hidden things, peek-a-boo, puts things in mouth, smoothly moves object from one hand to the other, picks up small objects with thumb and index finger

Movement/physical - stands while holding on, can get into sitting position, sit without support, pulls up to stand, crawls with abdomen off the floor, bang objects together with both hands. (number “9” looks like a figure standing)

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32
Q

9 Month Milestone Red Flags

A 
Not bearing weight on legs with support
Not sitting with help
Not babbling
Not playing games w/ back and forth play
Not responding to name
Not recognizing familiar people
Not looking where you point
Not transferring toys from one hand to another
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33
Q

12 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)

A

Social/emotional - shy/anxious around stranger, cries when mom/dad leaves, favorite toys and people, shows fear, hands book when wanting to hear story, repeats sounds/actions to get attention, puts our arm/leg to help with dressing, plays games (peek a boo, pat a cake)

Language - responds to simple spoken requests, uses simple gestures (shake head no, wave good bye), Sound changes in tone (sounds more like speech), says mama and dada and exclamations like uh-oh. Attempts to repeat words you say.

Cognitive - Explores in different ways (shaking, banging, throwing), easily finds hidden objects, looks at picture of named object, copies gestures, drinks from cup, brushes hair, puts things in/out of containers, more independent, pokes with index finger, follows simple directions (pick up toy)

Movement/physical - sits without help, pulls to stand, furniture surfing, few steps without holding alone, standing alone.

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34
Q

12 month milestone red flags

A 
Not crawling
Not standing while supported
Not searching for hidden objects
Not saying single words (mama or dada)
Not learning gestures (waving hand, shaking head)
Not pointing to things
Loss of skill child has previously had
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35
Q

18 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)

A

Social/Emotional - hand things to others as play, temper tantrums, afraid of strangers, affection towards familiar people, simple pretend (feeding doll), cling to caregiver in new situation, points to show interest, explores alone with parent nearby.

Language - several single words, shakes head no, points to show something they want

Cognitive - knows what simple objects are (phone, brush, spoon), points to get attention, interest in dolls or stuffed animals, points to body parts, scribbles on own, follows one-step commands (sit down)

Movement - walks alone, walk up steps, run, pulls toys while walking, undress self, drink from cup, eat with spoon

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36
Q

18 Month Milestone Red Flags

A 
Not pointing to show things to others
Unable to walk
Not knowing what familiar things are
Not copying others
Not gaining new words
Not knowing at least 6 words
Not noticing when caregiver comes/goes
Loses skill child previously had
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37
Q

2 Year Milestones (Social, Language, Cognitive, Physical)

A

Social - copies others, excited with other children, independence, defiant behavior, plays besides other children or with children (chase games)

Language - points to objects/pictures when named, knows names of people and body parts, 2-4 word sentences, follows simple instruction, repeats words overheard in conversation, points to things in books

Cognitive - Finds hidden things under multiple covers, sorting shapes/colors, completes sentences/rhymes in favorite books, builds towers of 4 blocks, uses one hand more than the other, follows two-step instructions, names items in picture books.

Physical - stands on tiptoes, kicks balls, run, climbs independently, up and down stairs, throws ball, copies lines and circles.

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38
Q

2 Year Milestone Red Flags

A 
Not using 2-word phrases
Not knowing what to do with common objects (tooth brush, silverware)
Not copying actions/words
Not following simple instructions
Not walking steadily
Loses skill child previously had
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39
Q

3 Year Milestones ( Social, Language, Cognitive, Physical)

A

Social - copies others, shows affection for friends, takes turn in games, shows concern for crying friend, understands “mine” “his” and “hers”, wide range of emotions, less separation anxiety, upset with major changes to routine, dresses/undresses self

Language - follows instruction with multiple steps, name most familiar things, understands words like in/on/under, says name age and sex, possessive nouns and plurals (I, me, we, you), carries on 2-3 sentence conversations

Cognitive - uses toys with buttons/levers/moving parts, plays with dolls/animals/people, small puzzles (3-4 pieces), draw circles, turns book pages, builds 6 block towers, screws/unscrews jar lids, turn door handle

Physical - climbs, runs, tricycle, stairs with one foot per step

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40
Q

3 Year Milestone Red Flags

A 
Troubles with stairs/falling down
Drooling
Unclear speech
Not speaking in sentences
Not understanding simple direction
Not playing pretend/make-believe
Not playing with other children
Not making eye contact
Losing skills child once had
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41
Q

4 Year Milestones (Social, Language, Cognitive, Physical)

A

Social - Enjoys new things, plays mom and dad, more creative with make-believe play, rather play with others than self, cant tell what’s real vs make-believe, talks about interests

Language - knows basic grammar rules, sings a song or rhyme from memory, tells stories, say first and last name

Cognitive - names colors/numbers, counting, starting to understand time, remembers parts of a story, understands difference between same and different, draw person with 2-4 body parts, uses scissors, copy some capital letters, plays board/card games, predicts what will happen in a book

Physical - hops and stands on one foot, catches a bounced ball, pours/cuts food with supervision

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42
Q

4 Year Milestone Red Flags

A 
Can't jump in place
Trouble with scribbling
No interest in interactive games/make believe
Ignores other children
Resists dressing/sleeping/using toilet
Can't retell a favorite story 
Doesn't follow 3-part commands
Doesn't understand difference between same and different
Not using "me" and "you" correctly
Speech is not clear
Loss of skill child once had
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43
Q

5 Year Milestones (Social, language, cognitive, physical)

A

Social - pleasing friends, agree with rules, sing/dance/act, aware of gender, can tell what’s real vs make-believe, more independence, demanding and cooperative at times.

Language - clear speech, simple story telling with full sentences, future tense, says name and address

Cognitive - counts 10 or more things, draw a person with 6+ body parts, print some letters/numbers, copies triangle and other shapes, knows about everyday things (food/money)

Physical - stands on one foot for 10+ sec, hops, skips, somersault, uses fork/spoon/knife, uses toilet on own, swings/climbs

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44
Q

5 Year Milestone Red Flags

A 
Not showing wide range of emotions
Shows extreme behavior (fear, aggression, shy, sad)
Withdrawn, not active
Not responding to people
easily distracted
unable to tell real vs make-believe
Can't give first and last name
Cant use plurals or past tense correctly
Not talking about daily activities/experiences
Not drawing pictures
Can't brush teeth, wash hands, or get undressed without help
Loses skill child once had
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45
Q

Premature Infants Adjusted Age

A

Premies may demonstrate delayed growth/attainment of developmental milestones

Always use adjusted age to evaluate growth and development for premature infants

Calculate by subtracting number of weeks infant was premature from the infant’s chronologic age.

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46
Q

Adjusted age for premature infant born at 30 weeks’ gestation at 4 month wellness visit

A

1.5 months old

4 months minus 10 weeks

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47
Q

Approach to Developmental Surveillance and Screenings (6 steps)

A
  1. Review checklists and developmental history
  2. Ask concerns
  3. Assess strengths and risks
  4. Observe child
  5. Document
  6. Obtain and share results with others (educators, WIC providers, home visitors, etc)
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48
Q

Developmental Surveillance vs Screening

A

Surveillance - “do you have concerns about development/behavior/learning?”

Screening - standard test to identify those at risk. Done with surveillance concerns and at specific routine visit. Determines need for further evaluation.

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49
Q

When to do standardized developmental screenings?

A

9, 18, and 30 months

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50
Q

When to do autism screening?

A

18 and 24 months

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51
Q

Denver II Screening Test

A

Cog & motor development

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52
Q

M-CHAT Screening Test

A

ASD

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53
Q

Vanderbilt Screening Test

A

ADHD

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54
Q

Pediatric Symptom Checklist Screening Test

A

Mental Health

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55
Q

ASD Facts

A

Begins early childhood and is a life-long disorder
Spectrum, ranging in severity
Delays may present differently at various ages
Child can develop typically, and then regress around 2 years of age

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56
Q

Autism Core Developmental Delays (3 areas)

A

Social communication (verbal and non-verbal)

Social interaction

Repetitive behaviors

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57
Q

ASD Treatment

A

NO CURE

Early intervention is key to improve child’s functioning.

Multidisciplinary treatment:

  • Applied behavioral analysis
  • OT
  • ST
  • Sensory integration
  • Alternative/complimentary treatment

* Behavioral Treatment of a Medical Diagnosis*

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58
Q

ASD Incidence

A

1: 27 boys
1: 116 girls

Occurs across all races, ethnic, and SES groups, BUT minority groups are diagnosed later and less often

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59
Q

Average age of ASD diagnosis

A

Age 4, but can be detected earlier in life

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60
Q

ASD Risk Factors

A

Genetics

Older parents

Parents w/ child w/ ASD have 2-18% chance of having a second child w/ ASD

Correlation of ASD in identical and fraternal twin studies

VACCINES ARE NOT A RISK FACTOR

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61
Q

ASD Communication Red Flags

A
  • Delayed speech and language
  • Echolalia
  • Not pointing
  • Not using gestures
  • No pretend play
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62
Q

ASD Social Interaction Red Flags

A
  • Avoids eye contact
  • Prefers solitary play
  • not responding to name by 12 mo
  • Not understanding personal space
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63
Q

ASD Behavioral Red Flags

A
  • lines up toys
  • obsessive interests
  • rigid routines
  • flapping hands
  • frequent rocking or spinning
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64
Q

ASD Traits - 0-6 mo

A

Lack of responsive Smile

Impaired social use of eye contact

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65
Q

ASD Traits - 6-12 mo

A

Impaired understanding and use of gestures

Lack of language and speech

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66
Q

ASD Traits 12-18 mo

A

Lack of showing or pointing out objects/interests

Failure to offer comfort to others/friends

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67
Q

ASD Traits 18-24 mo

A

Lines up toys obsessively

Enjoys non-functional play

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68
Q

ASD Traits 3yrs

A

Preference for solitary activities

Speech can be formal or repetitive

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69
Q

ASD Traits 4 yrs

A

Pronoun reversal

Lack of imaginative play

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70
Q

ASD Traits 5 yrs

A

Limits interaction with others
Not interest in attention from others
Unaware of others

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71
Q

ASD psychiatric comorbidities

A 
ADHD - 30-60%
Anxiety - 11-40%
Depression - 7% kids; 26% adults
Seizures - 30%
Tourettes
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72
Q

ASD GI comorbidities

A

Constipation
GERD
Abd pain
Diarrhea

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73
Q

ASD Sleep Comorbidities

A

Nightmares 50%
Sleepwalking 50%
Insomnia50%

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74
Q

ASD autoimmune comorbidities

A

DM

RA

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75
Q

ASD Screening Guidelines

A
  • complete developmental screening at every well child visit starting in infancy
  • Complete specific MCHAT ASD screen at 18 and 24 months
  • If positive, refer for further testing to establish diagnosis (ADOS test for autism)
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76
Q

ASD ALARM acronym

A

A - autism is prevalent (know statistics)
L - listen to parents (parents usually express their concern)
A - act early (screening and surveillance)
R - refer immediately, do not wait
M - monitor (follow-up, educate, advocate)

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77
Q

M-CHAT Screen

A

ASD screen completed at 18 and 24 mo
2-stage parent-reported screening tool to assess risk of ASD
- 20 yes/no questions, takes 5-10 min

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78
Q

Referral and Medical Tests for ASD

A

Role out other causes of developmental delay

  • Audiology - r/o hearing problems as cause of delayed speech
  • Lead screening - r/o other causes for PICA
  • Genetics - provide rationale for delayed milestones
  • Neurology - EEG to r/o seizures (mimics lateral gaze)
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79
Q

ASD Diagnosis

A

PCP screens for possible ASD and only qualified providers can DIAGNOSE
- psychologist, psychiatrist, developmental pediatrician, neurologist

DSM-V criteria for diagnoses

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80
Q

ASD Tips for Conducting a Medical Visit

A 
Simple and direct statements 
use toys and pretend play
Rewards and reinforcements
decrease wait time
Structured/smooth visit 
Visual aids with pictures
Have parent participate in assessment
Limit people in exam room and interruptions
Control noise level to create a quiet room
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81
Q

Newborn follow-up with PCP

A

D/C from hospital in:
<24H; f/u 2 days old
1-2 days; f/u by 4 days old
2+ days; f/u by 5 days old

Address weight, feeding, maternal health, bilirubin

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82
Q

Newborn Screening

A

Conducted on every baby born in the US, and is considered a public health service.

Conditions screened for varies by state and decided by the public health department

Recommended Uniform Screening Panel (RUSP) - guide of conditions to screen for (35 core conditions with 26 secondary conditions)

FREE OF CHARGE

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83
Q

Timing and collection of Newborn Screen

A

Heel stick

Important to do between 24-48 hours of life; some conditions aren’t detected until over 24 hours old

10-14 days for results, PCP follows up with results

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84
Q

Newborn screening results

A

Normal/Negative
- no further action

Borderline
- must repeat

Markedly out of Range
- referral to ER; metabolic specialist

Positive
- immediate response required

POSITIVE SCREEN DOES NOT CONFIRM CONDITION, REQUIRES FURTHER TESTING

85
Q

Neonatal Jaundice - Pathophysiology

A

Newborns have high Hct, but RBC have shorter life leading to high rate of hemolysis.
Hemolysis releases unconjugated bili into the blood.
NB liver inefficient at conjugating bili and excreting to GI tract.
Often develops within the firs 2-7 days of life then improves. Pathologic if persists beyond one week.

Can be neuro toxic if bili levels build up (crosses BBB) - leading to Kernicterus and cause damage to basal ganglia.

86
Q

Pathologic Neonatal Jaundice

A

Onset - <24H life and takes over 1 week to resolve
Conjugated bilirubin
Fast rise in bili levels

87
Q

Physiologic Neonatal Jaundice

A

Onset - after 72H and resolves within one week
UNconjugated bilirubin
Slow rise in bili levels

88
Q

Primary Prevention Neonatal Jaunice

A

Breast milk - promotes reabsorption and excretion of bilirubin in stool
Promote 8-12 feedings per day to prevent jaundice (feedings q2-3H)
If mom is not producing enough milk supplement with formula

89
Q

Neonatal Jaundice - Determining Risk

A

Calculating risk is most important step and guides necessary follow-up
Based on age (date and time of birth)
Date and time of serum bili sample collection
Risk rated low to high

90
Q

Intervention of neonatal jaundice based on risk

A

Low - no intervention
Medium - increase feeding frequency, natural sunlight for baby, repeat testing in 24H
High - hospital referral, phototherapy, and all of above interventions. F/u within 2 days of hospital discharge.

Outpatient - evaluate weight, stools, voiding, intake, and total bili level

91
Q

High Risk of Jaundice

A

Elevated total bili at discharge from hospital
Jaundice within first 24 hours of life is often pathologic
ABO incompatibility or positive Coombs test
G6PD deficiency
preterm (35-36 week gestation)
East asian race
Exclusive breast feeding (with poor milk supply)

92
Q

Coombs Test

A

Mothers antibodies attacking baby’s RBCs d/t Rh or ABO incompatibility

93
Q

Kernicterus

A

A bilirubin encephalopathy
-Unconjugated bilirubin is fat soluble and can cross the
blood brain barrier resulting in damage to the basal
ganglia
-Prognosis is based on timing of diagnosis. Results vary
from full recovery to significant neurological harm.

94
Q

Breastfeeding Recommendations

A

Exclusive breast feeding for first 6 months, then at 6 mo introduce other foods
Breast feeding should continue for the 1st year then as long as mutually desired

95
Q

Breastfeeding Keys to Success

A

Early initiation
Feed 8-12 times per day in the beginning (q2-3h)
Follow feeding cues and do not wait for cry before feeding
Positioning properly
Avoid pacifiers and supplements
Support and encouragement, relaxation

96
Q

Breastfeeding weight patterns

A

More rapid weight gain in the first 2 months, then less over the next 3-12 months
Dip in birth weight within first 10 days, then is regained by week 2

97
Q

Average elimination in newborn

A

6-8 wet diapers

2-5 stools per day

98
Q

Formula Feeding Guidelines

A

ONLY breastmilk or formula until 12 months
Whole milk after 1 yr
2% milk after 2 yrs
(milk binds with iron and can lead to anemia)

99
Q

Formula Safety Tips

A

Never give infant water (electrolyte imbalances)
Don’t warm in microwave
Never let infant sleep with bottle
Use only iron-fortified formula
Never keep formula at room temp for >2H
Discard bottle after 1 hour if feeding has begun

100
Q

Feeding Documentation

A

Document frequency of feedings and how long to empty each breast.
Feeding is a cardiac stress test and can identify congenital heart disease if infant fatigues quickly or becomes cyanotic with feeding

101
Q

Caloric Intake for Newborns

A

Infant requires 110-120 kcal/kg/day minimum

Document at each visit

102
Q

Vitamin D for Infants

A

Supports brain growth
Supplement with 400 IU daily for infants that are exclusively or partially breastfed
Formula is supplemented with adequate amounts
Levels can be very low in children with autism

103
Q

Vitamin K for Infants

A

Prevention of hemorrhagic disease (unable to make their own vit B and is not shared by mom, leading to blood not being able to clot properly)
0.5-1.0mg IM in immediate newborn period
50% with vit K deficiency bleeding will have a brain bleed
Babies that do not get Vit K at birth are at risk of bleeding until 6 mo

104
Q

Iron for Infants

A

Breast-fed infants require supplementation at 6 months (iron fortified cereal)
Formula-fed infants receive adequate supplementation

105
Q

Fluoride for Infants

A

No longer recommended at under 6 mo age

106
Q

Pacifier Use

A

Decreased success with breastfeeding if started too early (within first 3-4 weeks)
Only use in neonatal period for pain relief or to enhance oral motor function
Reduced rates of SIDS when used during sleep
Use during sleep/naps after breastfeeding is well established, after 3-4 weeks of age

107
Q

Umbilical Cord Care

A

Just keep clean and dry, do not apply alcohol on cord
Fold diaper below cord to prevent urine from soaking it
Usually falls off within first 2-3 weeks

108
Q

Introduction to Foods and Juice

A

Foods - starting at 6 mo; offer wide variety of healthy foods and textures; FE fortified cereal (not rice cereal)

Juice - no more than 1-5 oz/day, white grape is best tolerated, apple/pear linked to carbohydrate malabsorption and has high sorbitol content which helps constipation, citrus juice after 1st year (harder on GI tract)

Cup - use cup around 8-11 mo starting with a spout.

Soft finger foods - 8-10 mo
Mashed table foods - 8-12 mo
>9 mo- offer healthy snacks 2-3x/day in addition to three meals

109
Q

Introduction to food - Toddlers 1-3

A

Eat table foods in highchair or booster
Avoid high sugar/high fat snacks
Encourage self feeding, finger foods, spoon
Limit bottle and wean at 18 mo
Do not force child to eat if picky, respect strong dislikes and reintroduce later

110
Q

Preterm

111
Q

Late Preterm

A

34-36 weeks

112
Q

Term

A

37-42 weeks

113
Q

Post-term

114
Q

NB Assessment - Size

A

Term AGA (appropriate gestational age) - 5 lb 12 oz-8 lb 12 oz
SGA - <10th percentile
LGA - >90th percentile

115
Q

NB head assessment

A

Exam from above

Molding is common and resolves within the first week

116
Q

Microcephaly

A

2-3 SD below mean
Increased risk of learning disabilities
Etiology - genetics, poor nutrition, infection, fetal exposures
S/S - early fontanelle closure, prominent cranial sutures, downward sloped forehead, skull asymmetries, high arched palate
Requires referral

117
Q

Macrocephaly

A

2-3 SD above mean
Etiology - hydrocephalus, intracranial lesions, neurofibromatosis, familial (benign)
Progressive/excessive head growth, wide suture lines, delayed fontanel closing, signs of increased intracranial pressure, ocular abnormalities, cafe-au-lait spots, skeletal dysplasia
Requires referral

118
Q

Fontanelles

A

Soft and flat
Check in upright position
Anterior - diamond shaped, closes between 6-24 mo
Posterior - triangle shaped, closes between 2-3 mo

119
Q

Sutures

A

Approximated and mobile
May be split up to 1 cm
Should remain open until 2-3 yo
Premature closure - craniosynostosis (get skull x-ray)

120
Q

Brachycephaly

A

flat/short head

121
Q

Plagiocephaly

A

flat spot on head

122
Q

Scaphocephaly

A

long narrow skull

123
Q

Caput Succedaneum

A

Most common birth trauma
edema CROSSES suture lines
Resolves within several days
Caused by edema, can see finger indentation when pressed on

124
Q

Cephalohematoma

A

Collection of blood bound by sutures
Does NOT CROSS suture line
Does not require dx test, weeks to months to resolve
May lead to high bili levels

125
Q

NB Face Assessment

A

Symmetry, spacing, features
Facial movements during crying
Facial nerve palsy - common during birth w/ forceps use (resolves in days to months)

126
Q

NB Eye Assessment

A

Symmetry/formation, corneal light reflex, red reflex, pupil size equality, and pupillary reflex
Position - assessed by extending a line from inner eye to outer canthus towards ear
Otoscope exam is very difficult w/ NB
Hearing screen - eyes blink w/ sudden sharp sound
Cross eye/wall eye is normal until 4 mo
Tear formation starts at 2-3 mo
NL duct is not patent until 5-7 mo so it is common to have purulent/mucoid eye drainage
Iris color is dark gray/blue/brown at birth, and will reach final pigment at 6 mo

127
Q

NB Nose Assessment

A

Obligate nasal breathers for first 2 years of life
NB sneeze a lot (normal reflex)
Only maxillary and ethmoid sinuses are present at birth, and palpating in NB is not helpful

128
Q

NB Mouth Assessment

A

Inspect mucosa, tongue, gums, palate, tonsils, and posterior pharynx (best seen while crying)
Teeth in NB - 1:2,000 births (often w/ cleft palate, and requires removal)

129
Q

NB Clavicle Assessment

A

Common bone bx in NB (especially in LGA)

Greenstick fx - asymptomatic, decreased movement, deformity, crepitus, discoloration, asymmetry

130
Q

NB Neck Assessment

A

inspect for masses/adenopathy (extremely uncommon in NB)
Assess neck mobility
very short necks, and lengthens by 3-4 yo

131
Q

NB Chest Assessment

A

Chest wall is thin
Enlarged breasts common d/t mother’s estrogen and usually disappears by 2 weeks (may also see milky fluid from nipples - Witch’s Milk)

132
Q

NB CV Assessment

A

PMI in 4th ICS (not the 5th like in adults)
Check pulses - brachial, radial, femoral
Weak associated with COA
Bounding pulses associated with PDA (patent ductus arteriosus)
Cap refill is <1 sec
Murmurs in babies - flow murmurs (d/t PDA and tricuspid regurg)

133
Q

NB Abdomen Assessment

A

Sequence same as adults
Assess umbilical cord remnant, ascultate bowel sounds when baby is quiet
No need to routinely check rectal tone in NB (may beck for stenosis in NB w/ constipation)

134
Q

NB Female Genitalia Assessment

A

Can be prominent d/t maternal estrogen levels, and may have milky white vaginal discharge w/ slight blood tinge for first several weeks (not cause for concern)
Note vaginal opening (can get vaginal adhesions)

135
Q

NB Male Genitalia Assessment

A

Foreskin of NB is nonretractable at birth
Milk testes down to scrotum or inguinal (3% not descended)
Common scrotal masses - hydroceles and inguinal hernia (transillumination test)
- Hydroceles transilluminate and can not be reduced
- Hernias - usually reducible and do not transilluminate, require surgery

136
Q

NB Cryptorchidism

A

Undescended testes
Dx in NB period, and may lead to CA, torsion, and infertility in future if not fixed
Must refer to urology if unable to milk testes to scrotum (if unsure, refer)

137
Q

NB Nervous System Assessment

A

Inspect motor tone
Palpate tone through passive ROM of major joints
Reflexes
- NB - palmar, plantar grasp, moro, asymmetric tonic neck, positive support, ana, babinski +
- Infancy - Triceps, brachioradialis, abdominal reflexes starting at 6 mo

138
Q

NB Babinski Sign

A

Plantar stimulation causing dorsiflexion of big toe and fanning of others
Up to 10 beats are normal in NB and young infants, of sustained there may be a pathologic process

139
Q

Palmar Grasp Reflex

  • Maneuver
  • Normal Age
  • Red Flag
A
  • press finger on plantar surface and baby will flex fingers to grasp
  • birth to 4 mo
  • Beyond 4 mo indicates pyramidal tract dysfunction
140
Q

Plantar Grasp Reflex

  • Maneuver
  • Normal Age
  • Red Flag
A
  • Touch sole at base of toes and toes curl
  • Birth to 8 mo
  • Beyond 8 mo indicates pyramidal tract dysfunction
141
Q

Rooting Reflex

  • Maneuver
  • Normal Age
  • Red Flag
A
  • Stroke corner of mouth and mouth will open and head will turn towards stimulation
  • Birth to 3-4 mo
  • Absence indicates CNS disease
142
Q

Moro Reflex

  • Maneuver
  • Normal Age
  • Red Flag
A
  • Hold infant supported supine and abruptly lower about 2 feet, arms will extend, hands open, legs flex, baby may cry
  • Birth to 4 mo
  • Beyond 4 mo indicates neurologic disease (cerebral palsy), asymmetric response suggests fracture or brachial plexus injury
143
Q

Trunk Incurvation (Galant) Reflex

  • Maneuver
  • Normal Age
  • Red Flag
A
  • Support infant prone and stroke one side of back 1 cm from midline from shoulders to buttocks. Spine will curve towards stimulation.
  • Birth to 2 mo
  • Absence suggests transverse spinal cord lesion or injury, persistence suggests delayed development
144
Q

Landau Reflex

  • Maneuver
  • Normal Age
  • Red Flag
A
  • Support infant prone position, and head will lift up and spine will straighten
  • birth to 6 mo
  • Persistence = delayed development
145
Q

Parachute Reflex

  • Maneuver
  • Normal Age
  • Red Flag
A
  • Suspend baby prone and lower head towards a surface, arms/legs extend in protective fashion
  • Starts at 8 mo and does not go away
  • Delayed start may predict future delays
146
Q

Positive Support Reflex

  • Maneuver
  • Normal Age
  • Red Flag
A
  • Hold infant around trunk and have feet touch surface; baby will partially bear weight and stand up for about 20-30 seconds
  • Birth until 2-6 mo
  • Lack of reflex suggests hypotonia; fixed extension suggests spasticity from neuro disease (cerebral palsy)
147
Q

Placing and Stepping Reflexes

  • Maneuver
  • Normal Age
  • Red Flag
A
  • Hold infant upright and have one sole touch table, hip and knee/foot will extend and step forward, alternate stepping occurs
  • Birth (4 days after birth), and disappears at various intervals
  • Absence may suggest paralysis. Breech delivery infants may not have this reflex
148
Q

NB Musculoskeletal Assessment

A

Palpate and inspect, particular attention to hands, spine, hips, legs, feet
Check gluteal folds
Check alignment of feet (correct feet to neutral position), refer to ortho if unable
Ortolani Test - hip dysplasia, (you feel a clunk as the femoral head enters the acetabulum; refer to ortho
Barlow Test - tests for the ability to sublux or dislocate an intact but unstable hip
- Positive sign indicates laxity, not dislocation.
- Follow closely, refer to ortho

149
Q

Seborrheic Dermatitis

A
  • cradle cap; redness w/ greasy scales, occurs in 1st mo and is self limited; does not itch.
150
Q

NB Transient vascular phenomena

A

Normal mottling look in NB

151
Q

Harlequin Color Change

A
  • when laying on side, red on dependent side, blanching on other side. Lasts for 20 min and resolves with movement or crying. 2-5 days of life and up to 3 weeks
152
Q

Cutis Marmorata

A
  • Symmetric mottling of skin involving trunk and extremities in response to cold
153
Q

Erythema Toxicum Neonatorum

A
  • most common pustular eruption, appears in 2-3 days, flea bitten appearance, unknown cause
154
Q

Transient Neonatal Pustular Melanosis

A
  • 5% african american population, differentiate between ETN; these do not have surrounding redness and ruptures easily leaving a scale. Fades by 1 mo
155
Q

Acne Neonatorum

A
  • 20% NB, face, cheek, forehead. Hormones of baby/mom on sebaceous glands.
156
Q

Milia

A
  • pearly white papules, 50% NB. Spontaneously disappear
157
Q

Advisory Committee on Immunization Practices (ACIP)

A

Committee that meets annually to review guidelines on US childhood immunization.

158
Q

National Childhood Vaccine Injury Act of 1986

A
  • Signed into law by Reagan in 1986
  • goal to reduce potential financial liability of vaccine makers due to vaccine injury claims
  • Compensates people injured by rare, vaccine-related adverse reactions, providing liability protection for vaccine manufacturers and administrators
  • Provisions: Vaccine Adverse Event Reporting System, National Vaccine Program Office, Vaccine Information Sheets
159
Q

Vaccine Adverse Event Reporting System (VAERS)

A

Comanaged by CDC and FDA
Anyone can report; HCPs are required to report ADRs
Passive reporting; relies on reports that get sent in
Used to detect unusual/;unexpected patterns of reactions
Only tracks data, does not provide medical advice or judge the cause or seriousness of adverse reaction

160
Q

Vaccine Information Sheets (VIS)

A

Information sheets provided prior to vaccination
HCP should document information for each VIS provided
Charting: edition date of VIS distributed, date the VIS was provided, date of administration, information on who administered vaccine, manufacturer/lot #

161
Q

Immunity

  • definition
  • passive
  • active
A

Process of inducing immunity against a specific disease

  • Passive: (given), protection by antibody or antitoxin produced by one animal or human and transferred to another. Ex: temporary protection, maternal antibodies to infant
  • Active: (body makes); immunity after exposure to antigen (either natural infection or a vaccine); stimulates immune response.
162
Q

Live vs Inactive Vaccines

A

Live - derived from wild viruses/bacteria. The virus is attenuated (weakened) in a lab then given to individual. Immune response to live vaccine is same as actual exposure.
*Can cause severe reaction especially in weakened immune system (immunosuppressed individuals, those w/ hx splenectomy)

Inactive - virus/bacteria is not live and does not replicate. Generally require multiple doses to gain full immunity.
* Can NOT cause severe disease in weakened immune systems

163
Q

Vaccines for 17 diseases

A
  1. Varicella (chicken pox)
  2. Diphtheria
  3. Influenza
  4. Hep A
  5. Hep B
  6. Hib (Haemophilus influenzae type b)
  7. HPV
  8. Measles
  9. Meningococcal
  10. Mumps
  11. Pneumococcal
  12. Polio
  13. Rotavirus
  14. Rubella (german measles)
  15. Shingles (Herpes zoster)
  16. Tetanus
  17. Pertussis (whooping cough)
164
Q

How to use vaccine schedule (4 tips)

A
  1. Determine recommended vaccine by age
  2. Determine recommended interval for catch-up vaccination
  3. Assess need for additional recommended vaccines based on medical condition/other indications
  4. Review vaccine types, frequencies, intervals, and special considerations
165
Q

Chickenpox Vaccine

166
Q

Diphtheria Vaccine

167
Q

Haemophilus influenzae type B vaccine

168
Q

Hepatitis A vaccine

169
Q

Hepatitis B vaccine

170
Q

Measles Vaccine

171
Q

Mumps vaccine

172
Q

Pertussis Vaccine

173
Q

Polio Vaccine

174
Q

Pneumococcal Vaccine

A

PCV13 (prevnar)

175
Q

Rotavirus Vaccine

176
Q

Rubella Vaccine

177
Q

Tetanus Vaccine

178
Q

Hepatitis B Vaccine for Mother HBsAg - Negative

A

1 dose within 24 hours of birth (or at 1 month if premie)

179
Q

Hepatitis B Vaccine for Mothers HBsAg - Positive

A

HepB vaccine AND hep B immune globulin within 12 hours of birth

  • for premies <2,000g administer 3 additional doses for total of 4 beginning at 1 mo
  • Test for HBsAg and anti-HBs at 9-12 months
  • if series is delayed, test 1-2 months after final dose
180
Q

Hepatitis B Vaccine for mothers with unknown HBsAg status

A

Treat is if mother is positive, but only give hep b immune globulin if mother comes back positive
*determine mother’s HBsAg status as soon as possible

181
Q

Hepatitis B Vaccine Series

A

Routine: 3 doses at birth, 1-2 months, and 6-18 months
Begin as soon as possible for those who did not receive vaccine at birth
Minimum age for final dose is 24 weeks
Minimum Intervals:
- Dose 1-2: 4 weeks
- Dose 2-3: 8 weeks
- Dose 1-3: 16 weeks

182
Q

Rotavirus Vaccine (RV) Series

A

Live oral vaccine
Two types; RV1 and RV5. Either is okay, no preference.

RV1: Rotarix
- 2-dose series at 2 & 4 months

RV5: RotaTeq
- 3-dose series at 2, 4, 6 months

*if uncertain on type of RV used, or if RV5 was used as any of the doses, default to 3 doses total.

Catch-up vaccination: do not start series at 15+ weeks; max age for final dose is 8 months

183
Q

Adverse Reactions of RV (RV5 vs RV1)

A

RV5 - RotaTeq

  • diarrhea, vomiting after 1 week
  • OM, naso-pharyngitis, bronchospasm up to 42 days

RV1 - Rotarix

  • cough, runny nose after 1st week
  • Irritability/flatulence 31 days
184
Q

DTaP Vaccination Series

  • age
  • series
  • catch-up
A

For ages <7 years

5-dose series at 2, 4, 6, 15-18 months, 4-6 years
* dose 4 can be done as early as 12 months if there have been at least 6 months since previous dose

Catch up - dose 5 is unnecessary if dose 4 was given after 4 years of age and if there has been at least 6 months since dose 3

185
Q

DTaP

  • special situations
  • adverse reactions
A

Special situations: wound management in children <7yo who have received at least 3+ doses, administer DTaP if more than 5 years since previous dose

Adverse Reactions

  • local: pain/redness/swelling (especially after 4-5th doses)
  • entire limb swelling does not contradict future doses
  • Fever of 101F
186
Q

Tdap Vaccine Series

  • age
  • Routine series
A
  • For ages >7 yo; typically given at age 11

- Routine Series: adolescents ages 11-12yo for first dose; pregnancy 1 dose given around 27-36 weeks

187
Q

Tdap Special Situations

A

Wound management in ages 7+ with 3+ doses of tetanus containing vaccine:

  • Clean/minor wounds: Tdap or Td if 10+ years since last dose
  • All wounds: Tdap or Td if 5+ years since last dose

Tdap preferred over Td for those aged over 11 yo who have not previously received Tdap or who are uncertain if they have gotten vaccinated

Pregnant Adolescent - use Tdap

188
Q

HIB Vaccination Series

  • minimum age
  • types
  • series
A
  • 6 weeks minimum age
  • ActHIB, Hiberix, Pentacil, PedvaxHIB
  • ActHIB/Hiberix/Pentacil: 4-dose series at 2, 4, 6, 12-15 mo
    PedvaxHIB: 3-dose series at 2, 4, 12-15 mo

All HIB vaccines are interchangeable and can each be used as a booster, if different brands are used, child needs 3 dose series.

If child is unvaccinated at age 60+ months, and who are not considered high risk; no need to vaccinate

189
Q

Pneumococcal Vaccination

  • min age
  • series
  • catch up
  • high risk children considerations
A

6 weeks minimum age for PCV13; 2 years minimum age for PCV23

PCV13: 4 dose series; 2, 4, 6, 12-15 mo

1 dose for 2-5 years if series is incomplete; no further doses for healthy children if first dose was administered after 2 yr.

Conditions high risk: heart dz, DM, lung dz, SCD, HIV, leukemia, etc
When both PCV13 and 23 are indicated, give 13 first. Never give both at same visit.

190
Q

Polio Virus Series (IPV) <18 yr

  • min age
  • series
A
  • minimum 6 weeks

- 4 dose series at 2, 4, 6-18 mo, 4-6 years (final dose after age 4yr and must be at least 6 mo after 3rd dose)

191
Q

Influenza Vaccine Series

  • timing/series
  • types of vaccines (3) with minimum age
A
  • 2 doses after 6 mo; then 1 dose annually
  • Inactivated Influenza vaccine (IIV) - minimum age 6 mo
  • Live, Attenuated Influenza Vaccine (LAIV4) - minimum age 2 yrs
  • Recombinant Influenza Vaccine (RIV4) - 18 years
192
Q

Influenza vaccine special situations

A

Egg allergy w/ hives: give any influenza vaccine, annually

Egg allergy w/ angioedema/resp distress: any vaccine given annually and supervise in a medical setting.

193
Q

When to avoid live influenza vaccine (LAIV4)

A

Hx severe allergic reaction
Receiving ASA/salicylate medications
Children under 2 yo, or ages 2-4 with hx asthma/wheezing
Immunocompromised or close contacts of caregivers who are immunocompromised
Pregnancy
Cochlear implant or CSF-oropharyngeal communication
Received recent influenza antiviral medication

194
Q

MMR Vaccine Series

  • minimum age
  • routine series
A
  • minimum age: 12 mo
  • 2-dose series at 12-15 mo; and 4-6 yrs
    (dose 2 can be given as early as 4 weeks after first dose
195
Q

Varicella Vaccine Series

  • minimum age
  • series
A
  • minimum age 12 mo
  • 2 dose series, 12-15 mo; 4-6 years
  • dose 2 can be given 3 mo after first dose
  • can be given with MMR vaccine - MMRV (Proquad)
196
Q

Hepatitis A Vaccine Series

  • minimum age
  • series
A

Minimum age - 12 mo

2 dose series w/ 6 mo minimum in between doses

197
Q

HPV Vaccine Series

  • minimum age
  • series
A
  • minimum age 9 yo, often recommended to start at age 11
  • 2-dose series if started ages 9-14; w/ 6-12 mo interval in between
  • 3-dose series if started after 16 yo; at 0, 1-2, then 6 months
198
Q

Meningococcal Vaccine (ACWY)

  • minimum age
  • routine series
  • special considerations
A
  • min 2 mo for Menveo; 9 mo for Menactra
  • 2-dose series; 11-12 years; 16 years
  • First-year college students living in a res hall; or military recruit should get one dose if not previously vaccinated.
199
Q

Meningococcal B Vaccine Series

A
  • Shared clinical decision-making

- 2-dose series

200
Q

Pediarix Combination Vaccine

A

DTaP-HepB-IPV

201
Q

Pentacel Combination Vaccine

A

DTaP/IPV/Hib

202
Q

Kinrix/Quadracel Combination Vaccine

203
Q

Vacelis Combination Vaccine

A

DTaP-IPV-Hib-HepB

204
Q

ProQuad Combination Vaccine

A

MMR/Varicella

205
Q

Parental Vaccine Refusal & Role of HCP

A

Educate (make sure parent understands risk)
Take time to listen
Keep conversation going over each visit
Ask and answer questions; address parent’s concerns

206
Q

Vaccine Interval Tips

A

4 weeks = 28 days = 1 month

Intervals of >4 mo are determined by calendar months

Vaccines administered

207
Q

Patient without vaccine records

A

HCPs should only accept written/dated records as evidence of vaccination (exception for PPSV23 and flu)

Administer recommended vaccines if immunization hx is incomplete or unknown

208
Q

Reducing child’s pain with a vaccine

A
  • tasting something sweet reduces pain response; give small taste of sugar or breast milk several minutes before shot
  • cooling spray or pain relieving ointment helps child

N825 - Primary Care Pediatrics (2 decks)

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