Notes Flashcards
2 ways we track baby growth
Denver and growth chart
What is involved in the growth chart?
Height
Weight
Head circumference
What is in the denver developmental chart II?
Gross motor
Fine motor
Personal-social
Language
Normal child development marker at 3 months
Hold head up
Normal child development marker at 4 months
Rolls over
Normal child development marker at 6 months
Sits up
Normal child development marker at 9 months
Crawl/sit
Normal child development marker at 11 months
Stands/throws
Normal child development marker at 1 year
Walk/crawls freely
What is most common loss of point in appearance of APGAR?
Acrocyanosis
G in APGAR?
Grimace: are they reacting to noxious stimuli?
Second A in APGAR
Activity = are they moving both limbs equally? 0 = floppy
How will you check for developmental lag warning signs at 6-8 weeks old?
Flex hip, see if returns to normal position.
UE = usually in flexed position with spasticity.
LE = extended with toes pointed with spasticity.
Parents usually explain with difficulty changing a diaper.
T/F: can still be a head lag at 4 months
False. Should be no head lag at 4 months.
At what age do babies begin to get very social?
4-6 months
When would you see readiness signs for solid foods?
6-7 months
When should you see truncal control?
6 months
At what age should you see teeth growth?
7-9 months
What is a readiness sign for eating?
When teeth grow
When should you see hand to hand transfer? (Denver)
7-9 months
When will you see lumbar and sacral curve beginning to develop?
7-9 months
When will you hear sounds to first word? Nonspecific
7-9 months
When is object permanence developed?
8-10 months
What are some questions you would as a 7-9 month old baby?
Are they crawling? What’s the diet like? Have they introduced solid foods yet? What solid foods are they being introduced to? Have they spoken yet?
What age has a child tripled their birth weight?
10-12 months
When do you see a child speak 2-4 words?
10-12 months
Which babies tend to develop slower?
Premature and low birth weight babies. As long as there is a reason they develop slower, then don’t worry so much.
When should babies be walking?
16 months
When should you expect to hear two word phrases?
18-24 months
When should you expect 1000 words? >3 word phrases
Age 3
Pediatric history
Chief complaint (Well baby exam, new injury, special concerns)
Growht and developmental history
Obstetric history (in utero, delivery, post birth)
Nutrition/diet history (nursing, foods)
Habits (attitude, appetite, sleeping, bowel, bladder)
Past health history and family health history
What are 5 important questions about habits?
Change in attitude/personality? Appetite/feeding? Sleep? Night terrors? Bowel/bladder habits? Question to ask if child was injured from trauma/is ill?
Congenital infant conditions to watch for
CP Feet Clubfoot CHD Hearing Vision Brain Fetal alcohol
Birth trauma conditions to watch for
Torticollis Brachial plexus Clavicle fx Brain injury Head injury
Genetic conditions to watch for
Downs
Muscular dystrophy
Other conditions besides congenital, birth trauma or genetic to watch out for
Colic
Nursing difficulties
GER
Does infant seem ill? Look for:
Fever, normal vitals, rashes (SEARCH), mental status
Growth normal
Developmental delays
Personality/attitude changes
Sleep changes
Bodily functions WNL (change from normal. 1/2 to 3-6 day; 6-8 wet diapers/day; feedings 2-4 hours; normal appetite)
History taking tips (5)
Assume a position that puts you at eye level
Play before exam
Allow child to sit in parents lap
Begin with least invasive and move quickly
Involve child as much as possible
Newborn/infant PE (11)
W/in 12 hours of birth Pregnancy/birth history Growth measurements (ht, wt, head) Developmental evals Vitals HEENT Skin Cardioresp MSK nervous system Abdomen and genetalia Posture (extremities flexed and fists clenched - 2 months) Skin (lanugo, milia, erythema toxicum) Lungs Heart
APGAR scoring for color
0 = all blue/pale
1 = pink body, blue ext
2 - all pink
APGAR score for HR
0 = absent 1 = <100 bpm 2 = >100 bpm
APGAR score for respiration
0 = absent 1 = irregular, slow, cry 2 = good, cryin
APGAR score for reflex, stim
0 = none 1 = grimace 2 = sneeze/cough
APGAR score for muscle tone
0 = limp 1 = some flexion 2 = active
APGAR Scoring
8-10 = good to excellent 5-7 = fair <5 = neuro sequelae. Poor condition. Maybe immediate lifesaving mesasure such as o2 mask
Head/face exam (3)
Size, smmetry, alignment of skull, face, eyes, ears and nose, swelling?
Palpate sutures and fontanelles (should be open. Ant/post)
Fontanelles should be… (ant, post)
Ant: large diamond shape; open 1-4 cm at midline. Closes 18-24 months
Post: smaller; may be closed at birth = 6 weeks
When do sutures clos?
2-6 months
When does ant fontanelle close?
18-24 months.
Psot closes birth - 6 weeks
Plagiocephaly
Craniofacial asymmetry due to sustained pressure usually disappears by 2 years.
Cephalhematoma
Outlined by the bone. Boney and hard because it is under the periosteum.
This is more serious than caput succedaneum.
Subperiosteal hemorrhage doesn’t cross suture lines. Visible swelling might not be visible for few hours - 1 week and usually disappears in about 6 weeks
Caput succedaneum
Crosses suture lines
Benign and usually goes away in first weeks of life
Squishy and soft.
In newborn/infantn eval, how should infant be postured?
Extremities flexed and fists clenched
What is lanugo?
Fine body hair on shoulders, forehead and back
Milia
Small white papules on nose, cheeks and chin
Erythema toxicum
Maacular eruption common in light skin newobrn that resolves in 1 week
What are petechia and lesions a sign of?
Meningitis
Birth marks
Port wine stain (doesn’t blanch)
stork’s bite: upper eyelids, forehead, nape of neck, disappear by one year
Mongolion spots: dark blue/purple bruise on back/bottom in darker complexioned infants within first four years
Accessory supernumerary nipples
Heart murmurs
Birth - 1 week
10% association with congenital heart disease
Should be evaluated
Signs of distress
Include asymmetric chest movement, depressed sternum, absent breast tissue, flattened chest, nipples widely spaced, bowel sounds auscultated in chest
Cyanosis, grunting on expirations, nasal flaring, tachypnea, intercostal retractions
Where should liver be palpable?
2-3 cm below right costal margin
When should you hear bowel soudns
Within 2 hours of birth
When should you see meconium
Within i24-48 hours of birth
Abominal signs of distress
Absent bowel sounds Visible peristalsis Abdominal distention Palpable masses Red base of cord Cord with only two vessels
Neurmuscular system signs of distress
Hypotonia Quivering Limp extremities Spasticity Straightening of extremities Clonic jerking Paralysis
Neck signs of distress
Torticollis
Resistance to flexion
Neck webbing
Palpable crepitus in SC/AC joint
Two orthos to check for hip dislocation
Ortolanis
Barlows
Things we’ll see in a child who had untreated CHD
Assymetry of gluteal and thigh folds Limited hip abduction Apparent shortening of femu Positive trendelenburg sign Ortolani click Short leg side = CHD
What is CHD
Flattening of acetabulum so hip slides in and out. Laxity of hip area in newborn
CHD is MC in what gender babies
Girls.
MC orthopedic conditions you’ll see in this age group.
Barlow maneuver - how to perform
Adduct hip, apply light pressure on knee. Direct force posteriorly
If disolcates = positive.
Confirm with ortolani
Ortolani maneuver
Flex hips and knees of supine infant to 90 degrees. Examiner’s index finger places anterior pressure on greater trochanter, gently and smoothly abducting infants legs and examiner’s thumb.
Positive = clunk as femoral head relocates anteriorly in acetabulum.
POSTERIOR DISLOCATION test
Usually becomes negative after 2 months.
Moro reflex? And when you would see it
Birth - 4 months
Aka startle or parachute
Sudden extension and abduction of extremities and fanning of fingers
Tonic neck
Birth to 4-6 months
Infants head is turned to one side, arm and leg will extend on that side while opposite arm and leg may flex
Palmar grasp
Birth to 3-4 months
Plantar grasp
Birth to 8-10 months
Steps in place
Birth to 3 months
Babinski
Birth to 18 months
Clonus
Birth to 4 months
Rooting awake
Response birth to 3-4 months
Rooting asleep
Response birth to 7-8 months
Blink reflex
Bright light towards eyes. Should be symmetrical. Damage to CN II, VII
Present 3-6 months
Dolls eye reflex
As head is moved slowly, eyes do not move. Disappears as fixation develops (3 months)
Rooting reflex
Touching or stroking cheek by mouth = makes head turn toward that side
May disappear at 3-4 months or persist up to 12 months
Sucking
Birth to 10-12 months
Place nipple of finger in infants mouth.
Birth to 28 days =
Neonatal
PKU
Both parents have gene (1 in 4 chance)
First newborn screening test (since 1960s)
Cannot process phenylalanine which would build up in bloodstream and cause brain damage and mental retardation.
Sx’s start 1-3 months old.
Galactosemia
Can’t convert galactose (in milk) to glucose = blind (Cataracts), mental retardation, growth and developmental problems, nursing problems, decrease IQ, seizures
Congenital hypothyroid
1 in 4000
Retards growth and brain developmental
Biotinidase deficiency
Biotinidase Recycles biotin. Deficiency = seixures, skin abnormalities, death.
SEARCH
Socially interacting Energy state Apperance (color, tone) Reaction to parent (consolibility) Cry (strength, type) Hydration status
Leading cause of death in infants 1 month to 1 year
SIDS
Highest risk of SIDS
African american
Asian/hispanic = lowest risks
SIDS
No identifiable cause
1 month - 1 year leading cause of death
2-4 months of age, at night
Baby with more of a traumatic birth may have inflammation of foramen magnum area thus disrupting respiratory centers and causing death this way.
Considerations of SIDS
Premature/low birth weight babies
Mom ill during pregnancy (alcohol or any drugs)
Infants exposed to second hand smoke or toxins/irritants
Hx of difficult labor/delivery
Sleep positions
Apnea spells, bradycardia, cyanosis
Recommendations for SIDS
Place baby on back on firm surface and fitted sheets
Remove pillows, quilts and comforters from crib
Babys head must remain uncovered
Have baby share your room but not your bed
No smoke!
Craniosynostosis
Premture closing of sutures
Developmental disorder
Increased intracranial pressure and deformed head results. Affects brain development (IQ). Abnormal facial features.
May need surgery, sometimes in first 6 weeks
Hydrocephalus
Abnormal enlargement of ventricles d/t increased pressure = compression of brain!
Obstruction of CSF drainage/excess CSF production/decreased resorption into circulation
S&S of hydrocephalus
Macrocephaly, setting sun eyes, bulging fontanelles, abducens palsy, ataxia, increased ICP (pupil asymmetry, papilledema, bradycardia, HTN, focal neuro)
Seizures
Eval & Tx of hydrocephaly
CT/MRI of brain Lx puncture Surgical shunting of excess CSF Meds Underlying brain disease
Subdural hematoma
Immediate referral Dx via skull xray, CT scan, MRI Consider child abuse (shaken baby syndrome) Sx'al removal of blood clot or meds. Similar s&s as hydrocephalus
Cerebral palsy
Brain damage during gestation, birth process or in months after birth d/t hypoxia
CNS motor impairments - 75% spastic (pyramidal) spasticity, rigidity, dyskinesia, ataxia.
CP presentation
Clumsy (lack of balance & control)
Failure to achieve developmental milestones)
Limb spasticity = MC first sign
Leg spasticity in adduction, extension and IR = scissor gait pattern
CP management
Motor and movement abnormalities; difficulty with speech and movement
CT/MRI of brain, EEG, blood work, hearing/vision/cognitive testing
Tx: chiro, PT, counseling
Other disorders of infancy (2)
Conjunctivitis (referral) Cradle cap (ddx - seborrhea, psoriasis, eczema) top of head only. Daily wash with baby shampoo, gentle brushing with oil to loosen crusts
Common causes of recurrent infant crying
Feeding problems GI (GERD, constipation, allergy to milk, diseases) Abdomen problems (hernia, fissures) Head or nec kproblems (otitis media, strains/sprains, abrasions) Extremities (fx's, ingrown toe) UTI, obstruction Other: meningitis Trauma = birth
Infant colic syndrome
Excessive inconsolable crying episodes in an otherwise healthy infant.
0-3 months, >3 hrs/d, 3 d/wk for 3 weeks or more. Usually same time each day.
Cry and pull up legs, hard abdomen, relief with gas passing
Infant colic syndrome
When does infant colic syndrome work
1 month of age and resolves by 3 months or 6 months
Somatovisceral theory of infant colic syndrome
Upper cervical subluxations can cause interference with vagus nerve which controls gastric function
Infantile colic syndrome diagnosis
Of exclusion.
First rule out serious illness as cause for crying (intussusception/bowel obstruction’ Gi disease, pyloric stenosis, child abuse, drug rxn, OM, UTI, GI, URI, meningitis, GERD, allergy, lactose intolerance, nursing technique, parenting errors)
Ill child treatment protocol
Treatment trial - 2x/week for 2-3 weeks then re-evaluate
Crying diary
Usually children respond within 2-4 treatments; if no improvement within 4 treatments, consider other contributors (food sensitivites, nursing techniques)
Current research: upper cervical complex, t8-12 and cranial
4 S’s
Swaddle, swing, shushing, sucking
Positive features of breast feeding
Reduces infant mortality and morbidity from sepsis, gastroenteritis, RTI, asthma, SIDS, DM
Redsuce frequency of OM and food allergies, other GI symptoms
Less likely to be obese
Enhance mother-infant bonding
Breast milk firist 3-4 days
Colostrum (high in protein and immunoglob) helping with immunity and prepares GI tract to receive and make use of milk.
Crosses boob barrier
Alcohol
Drugs
Nicotine
Contraindications for breast feeding
TB
Hep B
Acute varicella, herpetic, syphilitic lesions
Not contraindications
Boob infections, UTI, group b strep or cytomegalovirus
Caution = alcohol, drugs, nicotine
When is the iron stored in babes body depleted by?
6 months. Little in boob milk. Thus may need supplementation of vit D.
Signs of readiness between 4-10 months = teething or tooth eruption
First foods
Rice Cereal Bananas Applesauce Pear Mild vegetables Fruits
Nonspecific allergy symptoms
Irritability, colic Rash around mouth, pruritis Red nose, ears, cheeks or buttocks Wrinkles under eyes, pallor Mouth uulcers Sleep distrubrances Flatulance, diarrhea, constipation, bloating, spitting up Fatigue Unpleasant body odors Infants with chronic recurrent ear infections, congestion, asthma = consider allergy
Allergenic foods = do not feed them these things
Honey, corn syrup, molasses to babies <1 year old because they may contain botulinum spores not neutralized by high pH of the gastric secretions in infants
Do not feed any fruit juice in great amounts of ?
4 oz
Regurgitation/vomiting DDX
Normal spititng up: GERD, excess feeding, air swallowing, nursing issues, food allergy/sensitivity, new drug, migraine, HA
GI dz: obstruction/blockage, appendicitis, GI, infection, pyloric stenosis (congenital), fistulas, duodenal atresia, IBS, accidental ingestion
Nonspecific: OM, UTI, URI, meningitis
Regurigtation/vomiting hx
New? Related to feeding? Normal appetite? Color/volue of vomit? Child = ill? Pain? Fever? New drugs or foods? Changes in habits (ppaas)? Diet? Normal BM and urinatino
Ppaas
Poop Pee Attitude Appetite Sleep
Red flags for referral
Blood in vomit or persistent vomiting (3/4 events)
Spitting up causes infant to choke/cough (PNA)
Abnormalities of exam (infection, obstruction, acute abdomen)
Underweight babies gaining weight or no appetite
Fever
Vomiting and diarrhea (infection, dehydration)
Vomiting and constipation (obstruction)
GER in infants. Why?
Immature sphincter
50-67% <4 months common
Episodic vomiting/spitting up in 1st 1-2 weeks of life
Resolves as baby grows up
GER treatment
Upright position post feeding
Burp 2x during feeding and after
Keep feeding to 20 mins or less
What is pyloric stenosis
Congenital stenosis of valve between ST and SI
Linked to neuromuscular control and poor breastfeeding
What begins as projectile vomiting in 1st week to month of life
Pyloric stenosis.
Feeding/nursing difficulties and failure to thrive. GROWTH CHART.
IMMEDIATE REFERRAL INDICATED.
Intussusception
Intestines are more mobile in infancy and can fold i on itself causing obstruction. MC CAUSE OF BOWEL OBSTRUCTION IN FIRST 2 YEARS
Symptoms of intussusception
Unctrollable crying (colic), irratibility, vomiting, constipation, tender palpable mass (RUQ0 URGENT REFERRAL INDICATED (air enema or surgery needed
Diarrhea in infants
Loose stools = normal in boob fed infants. # of BM's vary greatly Consider diarrhea if >8-10 BM/day and # or fluid content of stool has changed. If more than 8 watery stools per day and vomiting = danger of dehydration and loss of electrolytes.
Ddx for infant diarrhea
gastroenteritis (bacterial/viral). Viral = MC but must rule out bacterial (shigella, salmonelle, e.coli, campylobactor (blood) - need stool sample UTI, OM, URI (PNA), meningitis Food alergies Drug reaction Stress Too much juice
Red flags for infant diarrhea/constipation
Bloody stools
Abdominal pain and crying for more than 2 hours
Signs of illness = SEARCH
Dehydartion = lack of turgor, depression on anterior fontanelle, dry mucous membranes
Acute abdomen
Acute abdomen signs
Blood in stool Rigid abdomen Rebound tenderness Loss of bowel sounds Any masses
Treatment for diarrhea
Moderate - severe : IV
Mild = pedialyte and increase fluid intake
Gastroenteritis often caused by
Stomach flu (viral = rotovirus MC) d/t bacteria, food poisoning, parasite
Usually lasts 24 hrs - 5 days
R.o serious problem (stool sample)
Infant has persistent vomiting after nursing
Projectile = pyloric stenosis
MC in 1st born boys 3-8 weeks old
Triad: 1) projectile vomit 2)visible peristalsis 3) palpable olive mass
Diagnose = abdominal ultrasound
Urgent referral to MD for surgery: laparoscopic pylorotomy. Home in 2 days
Vomiting after nursing/eating and a rash
Allergy
If difficiulty breathing = anaphylactic rxn
If mild = explore diet
Vibrant green-yellow vomit
Color = bile (liver or GI obstruction which could be d/t birth defect, meconium blockage or twisted intestuine aka volvulus)
Bile stain = emergency
Recurrent vomiting with no obvious cause in otherwise healthy child
Cyclic vomiting syndrome; brain gut disorder (w/ migraine HA) often in cycles
Misdiagnosed and mistreated
Vomiting and fever and piercing cry or stiff neck
Ddx: bacterial meningitis; other signs HA, neck pain, lethargy/confusion/disorientation, seizures; nuchal rigidity/bruzinski’s >6 mo (not very reliable)
Medical emergency. Lx puncture needed to ddx viral from bacterial.
Vaccine
Vomiting and severe abdominal pain
Appendicitis (MC over 10)
Pain around belly that gets worse and moves to RLQ
Medical emergency
Constipation
1Bm every 2-3 days
Constipation ddx
Bowel/gi obsturction, anal stenosis, intussuception, impaction, hypothyroidism, botulism, other gi, hirschsprung, meds, dehydration
Tx of constipation
Co treat Over 6 months = increase water, fruits, veggies (prunes, apricots, pears), prune juice, veggie soup.broth, smoothie Increase fiber, fruits, veggies (psylium seed or flaxseed) Decrease stool hardening foods Abdominal massage Exercise OTC mulk of magnesium CMT (lx and sacral if abnormalities)
Stool hardening foods
Brat, dairy, sweets, yogurt, cheese, cereal, change formula
Persistent vomting after nursing
Pyloric stenosis
Vomiting and rash around mouth or face
Allergy
Bloody vomit/stools
Bacterial infection
Ulcer
Aspirin
Greeh-yellow vomit
Bile obstruction
Vomiting and diarrhea and fever
Gastroenteritis (viral or bacterial)
Vomiting and severe abdominal pain (rlq0
Appendicitis (esp >10 years)
Signs of acute abdomen 1) blood 2) rigid abdomen 3) rebound tenderness = peritonitis 911. ER
Vomiting and fever and piercing screaming cry and or rash and or stiff neck
Meningitis 911 ER
Vomting and constipation
Obsturction, intussusception
3 MC reported pediatric orthopedic problems during infancy
- Clubfeet
- DHD
- Congenital torticollis
Craniofacial asymmetry may result if contracture is not corrected in what condition
Congenital torticollis
If tumor on ddx of torticollis, should you adjust?
No. SCM innervated by CN Xi, also integrated with upper cervical nerves. Sometimes could be brain tumor. 3-4 adjustmetns should take care of it. If doesn’t get better, refer! With babies if it’s going to work it’s going to work quickly.
Ddx for torticollis
Pseudotumor of SCm - myofascial; congenital muscular torticollis
Upper cervical trauma/dislocation
Spinal cord tumor or othro tumor (bs)
Vertebral dislocation or fracture
2-% of infants with congenital torticollis have congenital/degenerative hip displasia
Congenital torticollis
Congenital muscular torticollis Birth trauma Klippel-feil syndrome Arnold chiari malformation Spina bifida
Acquired torticollis
Trauma
Infection (RA, retropharyngeal abscess, TB)
Neoplasm (posterior fossa, SC, BS, vestibular, vertebral column tumor, osteoid osteoma)
Neurogenic (syringomyelia, bulbar palsies)
Idiopathic
If negative x-ray, what next for treatment of torticollis?
Trial tx = 2x/week for 2 weeks and reeval (CMT and STM)
If SCM mass, more likely biomechanic. Tyus do what
SCM TP and C/S ISD
No SCM mass =
Bigger concern for serious pathology
Benign causes of torticollis
Muscular
Joint dysfunction
Resolve quickly with appropriate treatment
Large baby small framed mother force needed for birth, breech
Brachial plexus stretch injury Neuropraxia 3-6 months for healing Start tx 3-4 weeks old Surgery option if incomplete healing
Infantile erb-duchenne’s palsy
Unilateral traction injury to brachial plexus (c5-6) during delivery
Mild cases = self limiting
Severe =residual paralysis
LMN paralysis of deltoid, biceps, brachialis and brachioradialis over c5/6 dermatomes.
Waiter tip deformity
Infantile erb duchene palsy
Infant can’t abduct or flex shoulder or flex elbow
Arm in adduction, elbow extension and internally rotated
Erb’s palsy c5-7 nerve
Damage wrist drop; assocaigted with birth trauma
Klumpke’s palsy c7-t1
Ortlani’s sign
DHD/CHD
Diagnostic criteria for CHD: perinatal risk factors
Breech, female, low amniotic fluid, quick discharge from hospital, primiparity, large weight, rural birth
Diagnostic criteria for CHD
Ultrasound
Ortlani’s and barlow tests
Signs and symptoms = CHD
0-3 months = parent may notice decreased abduction (diaper changes); babies hips should abduct enough to lay flat on exam table or notice short leg
4-11 month = trouble crawling
Once walking = limp or waddle
Treatment CHD
Early dx and tx = pavlik harness
Von rosen splint, spica casting or surgery
Prevention: webster! Change breech, proper swaddling (free hips
