Pediatrics - Developmental Pediatrics Flashcards
1
Q
When can solid foods be introduced into the diet in an infant?
A
4-6 months of age Vegetable first (green to orange), then fruits
2
Q
What foods should be avoided until after 1 year of age?
A
Honey, cow’s milk, egg whites and nuts
3
Q
Why must cow’s milk be avoided until after 1 year of age?
A
Does not contain the appropriate balance of protein, fat and water
4
Q
What causes breast feeding jaundice?
A
A failure to establish adequate breastfeeding
Abnormal unconjugated hyperbilirubinemia during 1st week of life
5
Q
When does breast feeding jaundice occur?
A
1st week of life
Abnormal unconjugated hyperbilirubinemia
6
Q
What is the difference between the onset of breast milk and breast feeding jaundice?
A
Breast Feeding jaundice occurs in the First week
Breast Milk jaundice occurs Many weeks later
7
Q
What causes breast milk jaundice?
A
Caused by an inhibitor of bilirubin conjugation present in human milk.
8
Q
When does breast milk jaundice occur?
A
It begins after the fifth day of life and continues for several weeks.
9
Q
What is the typical presentation of an infant with breast feeding jaundice?
A
Infants are fussy or sleepy and difficult to arouse accompanied by inadequate weight gain.
10
Q
What is the presentation of an infant with breast milk jaundice?
A
Infants are well appearing and alert, though they may experience inadequate weight gain.
11
Q
How is breast feeding jaundice diagnosed?
A
Measurement of bilirubin levels, looking for indirect hyperbilirubinemia
12
Q
What is the treatment for breast feeding jaundice?
A
Treatment involves ensuring adequate breast milk intake and supplementation with formula, if necessary.
13
Q
What is the treatment for breast milk jaundice?
A
No specific treatment is necessary as it is a transient condition. Breast feeding should be continued.
14
Q
When is protein hydrosylate-based formula indicated for infants?
A
Patients with malabsorption issues or food allergies to cow’s milk and soy milk.
15
Q
When is soy protein-based formula indicated for infants?
A
Patients who have galactosemia or lactose intolerance.
16
Q
When is high medium-chain triglyceride oil indicated for infants?
A
Patients who have had or have a tendency toward chylous ascites or chylothorax.
17
Q
When is cow’s milk-based formula indicated for infants?
A
Newborns without special nutritional needs whose mothers cannot or do not wish to breastfeed.
18
Q
When is amino acid-based formula indicated for infants?
A
Patients with food allergies or short bowel.
19
Q
What are some inappropriate substitutes for infant formula?
A
Cow’s milk
Goat’s milk
Rice milk
Soy milk
20
Q
What three vitamins and minerals is cow’s milk deficient in?
A
Iron, essential fatty acids, vitamin E
21
Q
An infant is fed goat’s milk. What disorder may develop?
A
Allergic reaction
Renal solute loading due to high protein content
Megaloblastic anemia due to low iron and folate content
22
Q
What disorder can result from strictly soy milk fed infants?
A
L-thyroxine depletion through fecal waste
Increases requirement for iodine, leading to goiter
23
Q
How does proportionate (symmetrical) microcephaly differ from disproportionate (asymmetric) microcephaly?
A
Proportionate (symmetric) microcephaly describes a child with a head circumference, height and weight that are similarly below average for age.
Disproportionate (asymmetric) microcephaly, on the other hand, describes a microcephalic child with an otherwise normal height and weight.
24
Q
What are two precise criteria for diagnosing microcephaly?
A
Head circumference more than 2-3 standard deviations below the mean or less than the 3rd percentile for a child’s age.
25
What is the pathophysiologic mechanism of acquired microcephaly, and how does this relate to its time of onset?
Caused by injury to a previously normal brain (i.e. neuronal damage), which manifests as a child with a normal head circumference at birth that grows at abnormally slow rate thereafter..
As a result, the child’s head circumference will cross multiple percentile lines when plotted over time on standardized growth charts.
26
What are three neurologic symptoms commonly associated with microcephaly?
Seizures
Intellectual disability
Developmental delay (motor, language, etc.)
27
What are three general causes of acquired microcephaly?
Environmental insults at birth (e.g. hypoxic-ischemic encephalopathy, intraventricular hemorrhage, trauma - cerebral palsy)
Environmental insults in early childhood (e.g. infection, hypothyroidism, malnutrition)
Metabolic genetic disorders (e.g. PKU)
28
What is the relationship between microencephaly and microcephaly? Does one always accompany the other?
Microcephaly is detected by physical exam
Microencephaly is detected by neuroimaging
Microencephaly always accompanies microcephaly, except in generalized craniosynostosis
Microencephaly may also be present in a child with normal head circumference
29
What is the presentation of isolated microcephaly, and what is unique about this presentation compared to more common types of microcephaly?
Asymptomatic, congenital, proportional microcephaly in a patient with a positive family history
Associated with normal neurologic function
30
A newborn is noted to have microcephaly. What additional findings in the history and physical exam might lead one to suspect congenital or perinatal CNS infection?
Petechial rash
Congenital cataracts
Hepatomegaly/jaundice
Symptoms of meningitis
31
If MRI of a microcephalic patient's brain is normal or nonspecific, what further testing is indicated?
Testing for toxic, genetic, metabolic and endocrine disorders
32
How is failure to thrive defined?
Inadequate use of calories
| Weight gain is generally most abnormal
33
What action is required for non-organic causes of failure to thrive?
If a non-organic cause is suspected and the child is severely malnourished, hospitalization is required. If the cause is organic, treat the cause.
34
Which growth parameter is affected first in infants with failure to thrive? Which is relatively spared?
In failure to thrive weight is affected first, followed by height, and then head circumference.
35
A child with failure to thrive has short stature with normal weight gain but a low linear growth rate – what general causes should be considered?
Genetic syndrome
Teratogen conditions
Endocrine conditions
36
What is the most common clinical presentation of failure to thrive?
Poor growth with a weight decrease that crosses two major percentile isobars on standardized charts.
37
What are some of the signs of failure to thrive in an infant?
Some clinical signs of failure to thrive include: SMALL KID
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Subcutaneous fat loss
Muscle atrophy
Alopecia
Lagging behind norms
Lethargy
Kwashiorkor/marasmus
Infection
Dermatitis
```
38
If a child with failure to thrive has short stature with low weight what cause should be considered?
Inadequate nutrition
39
If a child with failure to thrive has microcephaly with neurologic signs and poor nutrition, what causes should be considered?
TORCHES infections
Teratogen exposure
Genetic syndrome
Brain injury
40
What are common causes of malnutrition in infants 0-6 months old?
Common causes of malnutrition in infants 0-6 months old:
```
Breastfeeding difficulties
Improper formula preparation
Impaired parent/child interaction
Congenital syndromes
Prenatal infections or teratogenic exposures
Poor feeding (sucking, swallowing) or feeding refusal (aversion)
Maternal psychological disorder (depression or attachment disorder)
Congenital heart disease
Cystic fibrosis
Neurologic abnormalities
Child neglect
Recurrent infections
```
41
What are common causes of malnutrition in infants 6-12 months old?
Common causes of malnutrition in infants 6-12 months old:
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Celiac disease
Food intolerance
Child neglect
Delayed introduction of age-appropriate foods or poor transition to food
Recurrent infection
Food allergy
```
42
Developmental Milestones: 1 month
Motor: reacts to pain, make tight fists, hold head up
Language: ability to cry
Social: establishes eye contact, fix on red ring
Red flag: failure to alert to environmental stimuli, which may indicate sensory impairment
43
Developmental Milestones: 2 months
Motor: eyes follow object to midline, lifts head 45 degrees
Language: coos, makes gurgling sounds, turns head toward sounds
Social: social smile, tries to look at parent
Cognitive development: Pays attention to faces, follows with eyes, can become bored if activity doesn't change
Note: rolling over earlier than 3 months may indicate hypertonia
44
Developmental Milestones: 4 months
Motor: holds head steady and unsupported, rolls over, eyes follow object past midline, can shake a rattle
Language: begins to babble
Social: smiles spontaneously at people
Cognitive development: reaches for toy
45
Developmental Milestones: 6 months
Motor: sits well unsupported, transfers objects from hand to hand, rolls prone to supine ("back to belly"), raking grasp
Language: babbles, responds to own name
Social: recognizes strangers
Red flag: absent babbling at 6 months - obtain a hearing test
46
Developmental Milestones: 9 months
Motor: crawls, stands while holding onto something, sits without support
Language: "mama/dada," alert to sound of own name, uses fingers to point
Social: stranger anxiety
Cognitive: plays peek-a-boo, puts things in mouth
Red flag: persistence of primitive reflexes (except Babinski) may indicate neuromotor disorder
47
Developmental Milestones: 12 months
Motor: walks holding onto furniture ("cruising"), may take a few steps without holding on, fine pincer grasp, builds tower of two cubes
Language: knows 5-10 words, shakes head, waves "bye bye"
Social: cries when parent leaves
Cognitive: starts to drink from a cup, brush hair
Red flags: failure to develop protection reactions may indicate neuromotor disorder; persistent mouthing of objects may indicate lack of intellectual curiousity
48
Developmental Milestones: 2 years
Motor: walks up and down stairs, copies a line, runs, kicks ball, jumps in place
Language: 2-3 word phrases, refers to self by name, uses 50+ words
Social: parallel play, mimics domestic activities, able to take turns
Cognitive: plays make-believe games, builds tower of four or more blocks, follows two-step directions, can sort shapes and colors
Red flags: inability to walk up or down stairs may be the result of lack of opportunity;
absent symbolic play may indicate problems in cognitive and/or social development
49
Developmental Milestones: 3 years
Motor: pedals a tricycle, walks down stairs with alternating feet, able to stand on one foot
Language: 3/4 of speech is understood by strangers
Social: group play, simple fantasy play, separates easily from parents
Cognitive: copies circle with pencil/crayon
50
Developmental Milestones: 4 years
Motor: brushes own teeth, copies a square, hops and balances on one foot, dresses self, including buttons
Language: stranger can understand 100% of speech, identifies colors, uses 4-word sentences
Social: goes to toilet alone, prefers social play over playing alone
Cognitive: starts to understand time
51
Developmental Milestones: 5 years
Motor: can stand on one foot for 10 seconds, catches ball, skips with alternating feet, ties a knot
Language: tells a simple story, says name and address
Social: can distinguish fantasy from reality, wants to please friends, follows rules of the game
Cognitive: Counts 10 or more things, copies a triangle, can draw a person with at least 6 body parts
52
What is the galant reflex?
The infant’s pelvis will move in the direction of the stimulated side when you stroke the paravertebral region of the back. This reflex is present from birth to 2-6 months.
53
How is the parachute reflex displayed by an infant?
Hold infant upright, then quickly rotate body a few centimeters toward ground.
The infant will extend his or her arms forward as if to break a fall.
Not present at birth, but by 9 months of age, in preparation for walking.
54
What is the startle reflex?
Arms and legs flex immediately when baby is startled. It is present from birth to 5-6 months
55
When does the Babinski reflex begin to disappear in an infant?
It begins to disappear around 6 months of age, but is considered normal up to 2 years of age.
56
How does the rooting reflex present?
The baby’s head will turn toward the stimulus when stroked from the mouth to earlobe. Once the baby’s head is turned their mouth opens.
Disappears after 1 month of age
57
How is the parachute reflex unique?
Not present at birth, but appears at about 9 months of age, presumably in preparation for walking, and is present throughout life.
58
How long does the sucking reflex persist in infants?
Sucking becomes voluntary at 3 months of age
59
What is the palmar/plantar grasp reflex?
Stimulation of the palm or plantar surface of the foot will cause the baby to grasp or plantar flex.
Present until 6 months of age
60
What is the moro reflex?
Symmetric extension and abduction, then flexion of limbs occurs when the baby is subjected to the sensation of falling.
Present until 6 months of age
61
What is the tonic neck reflex?
The head of a supine infant is moved to one side causing extension of the limbs on the side the head is facing and flexion of limbs on the opposite side.
Referred to as "the fencing pose"
Present until 6 months of age
62
American Academy of Pediatrics (AAP) recommendations for breastfeeding
Exclusive breastfeeding for about 6 months followed by continued breastfeeding for 1 year or longer as desired
63
Stage 1 of lactogenesis
High levels of progesterone prevent milk (colostrum) secretion during mid-pregnancy
64
Stage 2 of lactogenesis
Progesterone levels fall and milk is produced on days 2-5 after birth
65
How does colostrum differ from breast milk?
Colostrum has more protein (IgA), lactose, and lower fat content than milk.
66
What is purpose of colostrum?
Milk secreted on days 1-2 after birth
Helps clear bilirubin from the infant's gut due to high RBC turnover during blood volume contraction in first weeks of life, helping prevent jaundice
67
When is the most common time for mothers to experience breast engorgement?
Days 2-5 after birth, during stage 2 of lactogenesis
Occurs when breasts are not drained properly
68
What types of supplementation may be required in a breast feeding infant?
Vitamin K at birth
Vitamin D, daily
Fluoride after 6 months
Iron from 4-12 months
69
How are metabolic types of macrocephaly caused?
Result from cellular edema or abnormal accumulation of metabolic substrates within neurons
70
What are some metabolic causes of macrocephaly?
Lysosomal storage diseases, mucopolysaccharidoses, leukodystrophies
71
What is the definition of macrocephaly?
Occipital-frontal circumference greater than or equal to 2 standard deviations above the mean
72
What is the most likely cause of macrocephaly if a patient has accelerated head growth with increased intracranial pressure?
Hydrocephalus
73
What are some developmental causes of hydrocephalus?
Chiari II malformation
Craniosynostosis
Foraminal atresia
74
What are some acquired causes of hydrocephalus?
Posthemorrhage
Postinfection
Tumor
75
What are three clinical signs that can be used to establish the etiology of macrocephaly?
Head growth rate
Developmental milestones
Signs of increased ICP (bulging fontanelle, split sutures, papilledema)
76
What is familial megalencephaly?
Normal growth rate, normal neurological exam
| Benign condition in which children have a larger than normal brain mass
77
How does anemia cause macrocephaly?
Chronic hemolytic anemia will induce bone marrow hyperplasia due to cellular proliferation in bone marrow in response to anemia
78
How are anatomic types of macrocephaly caused?
Increased size or number of cells due to either overproduction of cells or failure of apoptosis
79
What is the most likely cause of macrocephaly if a patient has increased growth rate after an illness of prematurity?
Rebound brain growth
Seen in a thriving infant after prematurity or a period of deprivation or serious illness
80
If an infant has an increased growth rate with a normal neuro exam and normal developmental milestones, what is the most likely cause of macrocephaly?
Benign extracerebral collections of infancy (BECC)
Due to delayed development of parasagittal dural channels responsible for CSF absorption
Results in accelerated head growth until 12-18 months that eventually stabilizes
81
What etiologies for macrocephaly should be considered if an infant has an abnormal neuro exam, developmental delay, seizures, and/or systemic disease?
Dysplastic megalencephaly
Metabolic disorders
Anemias
Cranial dysplasias
82
Developmental Milestones: 18 months
Motor: walks backward, drinks from cup, eats with spoon
Language: 2-word sentences, says and shakes head "No"
Social: parallel play, points
Cognitive: scribbles on his own, points to one body part
Note: autism screen is often performed at 18-month well-child visit
83
What is the name of the growth chart used for premature infants?
Babson
84
After an initial loss of weight, when do term infants regain their birth weight?
2 weeks of age
85
When do newborns begin feeding?
Within first 6 hours of life, taking place every 2-3 hours and total 2-3 oz per feed
86
How much does a child’s length increase by one year of life?
50% increase in length by one year of life
87
When does a newborn/infant double and triple its birth weight?
Doubles by fifth month of life
| Triples by one year old
88
How long does a practitioner have to adjust growth charts for gestational age?
Until the infant is 2 years old
