Pediatrics intro Flashcards
define postmenstrual age
postmenstrual age- age from 1st day of the last menstrual period
gestational age, chronological and corrected ages are more frequently used
define chronological age
chronological age- actual age of the born baby
define corrected age
Corrected age, or adjusted age, is your premature baby’s chronological age minus the number of weeks or months he was born early. e.g. baby born 10 weeks early and now he is 3 month-> 12 completed weeks since being born; out of 12 weeks: 10 weeks of pregnancy and 2 weeks of his age that he would have been born
define gestational age
gestational age- from 1st day of last menstrual period till the day of birth; used for a period of pregnancy till birth; used to describe the age of premature infant e.g. a child born 10 weeks early-> gestational age of 30 weeks (30 out of 40)
list gestational, chronological, corrected and postmenstrual age of a bb that is 10 weeks premature and u see him 3 month after being born
baby has 42 weeks postmenstrual, 42 weeks gestational age, 2 weeks corrected age and 12 weeks chronological age
how old should an infant be to be considered viable?
22 weeks
until what age is GA age used for preterm bbs? why
usually corrected Ga age is used until baby is 2 years-> this is more reflective of possible issues
definitions of different stages of pre-term and pos-term infants
- Preterm:GA<37 weeks at birth
- Extremely preterm: GA<28 weeks at birth
- Very preterm:28-31 6/7 weeks at birth
- Moderately preterm: 32-33 6/7 weeks at birth
- Late preterm: 34-36 6/7 weeks at birth
- Term: GA>37 weeks
- Postterm: 42 to 46 weeks after birth
Birth weight classification
- Microprem: <750g at birth
- ELBW: <1000g at birth
- VLBW : 1000-1499g at birth • LBW : 1500-2500g at birth
- Normal : <2500g at birth
- SGA: < 10th %ile birthweight for GA
- AGA: 10th - 90th %ile birthweight for GA
- LGA: >90th %ile birthweight for GA
what is IUGR?
Intrauterine growth restriction
• Failure of the fetus to achieve normal predicted growth in utero
what are the causes of IUGR?
probably had compromised nutrition while in utero
usually happens early-
before 2 weeks
types and causes of IUGR
Symmetric IUGR: 20-30% of all cases of IUGR
• Weight, length and head circumference less than 10th %ile.
- Indicative of chronic malnutrition
common causes:
- genetic disorder-> smaller potential of growth
may be due infections during
pregnancy
- early onset
Asymmetric IUGR
• Length and head circumference are appropriate but weight is below the 10th %ile. Better head sparing Indicative of an acute insult in nutrition usually in 3rd trimester
characteristic of acute insult- not enough nutrition or oxygen due to placental insufficiency (preeclampsia)
which score is used to assess health at birth?
Apgar
describe APGAR score
Appearance, Pulse, Grimace
Activity, Respiration
- Neonatal health assessment
- Scored out of 10 at 1 min, 5mins and 10 mins
- Provide information on delivery event
- Risk of perinatal depression
when is mid-upper arm assessment is used?
Mid-upper arm: more in community and research setting, reflects malnutrition
when is upper arm and lower limb assessment used?
handicap kids
fenton’s growth chart is used for which kids?
pre-term
fenton vs WHO
who is used for term infants
what are the types of WHO growth curves for brith-24 months babies
- length for age and weight for age
2. head circumference and weight for length
which ages are covered by WHO curves?
- birth-> 24 months
2. 24 month-> 19 yo
what are the types of WHO growth curves for 24 months-> 19yo
- height for age and weight for age
2. BMI for age
is weight or BMI a preferred method of assessment in curves for teens? Why
BMI
teens go through growth spurts at different points-> different weight at the same age
Specialized growth charts are available for the following conditions:
- Prader-Willi syndrome
- Cornelia deLange syndrome
- Turner syndrome
- Trisomy 21 (Down’s syndrome)
- Rubinstein-Taybi syndrome
- Marfan syndrome
- Achondroplasia
Interpreting growth chart
When to be worried?
Plateauing: bb is not growing over time-> sign of chronic malnutrition
Falling off 50th %ile: bb is growing over time, but not fast enough-> sign of chronic malnutrition
Sharp decline: losing weight-> acute malnutrition e.g. trauma
Incline in BMI: child is gaining too much weight
Common Anthropometric Criteria for Diagnosing Failure to Thrive
Body mass index for age less than the 5th percentile
Length for age less than the 5th percentile
Weight deceleration crossing two major percentile lines (most common definition)
Weight for age less than the 5th percentile
Weight less than 75 percent of median weight for age
Weight less than 75 percent of median weight for length
Weight velocity less than the 5th percentile
more severe cases of failure to thrive is when
more severe cases of failure to thrive is when length and head circumference is also being affected, not just weight
Interpreting linear growth chart
congenital growth hormone deficiency
no need for nutritional intervention, but there is a need for hormone supplementation when hormones are supplemented, the growth will return to normal
the weight does not fall in the way that height does
Interpreting linear growth chart
Constitutional delay of growth and adolescence
curve starts to fall from 3rd percentile typically: small at first then rapid growth
no need to intervene
Interpreting linear growth chart
familial or genetic short stature:
short genetic potential, nothing u can do weight and height follow the same pattern
Interpreting linear growth chart
primary nutritional deficiency and severe illness:
weight starts to fall below 3rd percentile linear growth curve occurs in delay, later than weight
this signals for chronic malnutrition -> need for intervention
What is the first and the last thing to be affected in case of malnutrition on linear growth charts?
head crmc is the last thing to be affected in case of malnutrition
weight is the first things affected, the next is linear growth
how are weight and height affected when nutritional support is administered
weight will improve first, followed by the height
stunting- changes after administering nutritional support
may take years for height to improve
what are good markers of chronic malnutrition
height and head circumference
what are good markers of acute malnutrition
weight
__ is the adaptive response to suboptimal nutrition
Growth deceleration is the adaptive response to suboptimal nutrition
Interpreting linear growth in Stunting or Nutritional Dwarfism:
• -2 SD below the height for age curves; not necessarily associated with emaciation; short stature or poor growth may be the sole manifestations of nutritional inadequacy
Interpreting linear growth” Short stature
need for nutr intervention?
no nutritional intervention • Familial/genetic • Growth is parallel to the normal centile usually below the 5th %ile • Final adult stature is short - no need for nutritional intervention
to decide genetic vs nutritional cause of short stature :
1) check literature for child’s condition and expected growth
2) calculate mid parental height
What is post-natal fluid adaptation
In the wob, baby was surrounded by fluid-> now it is in the environment with no fluid
changes occur:
• Efflux of fluid ICF to ECF
• Excess ECF floods neonatal kidneys
Phases during the 1st week of life
dietary intake
urine output
weight
Prediuretic phase Age: birth - 2 days dietary intake: few drops urine output: low proper milk let-down weight: wt loss due to water loss via skin
Diuretic phase Age: 1-5 days dietary intake: low urine output: abrupt increase as kidneys start working more weight: wt loss
Homeostatic phase Age: after 2-5 days dietary intake: increase urine output: decreases, then proportional to intake weight: start to regain
is weight loss normal in newborns?
weight loss after birth is normal for both term and preterm
First week of live: term vs preterm in terms of acceptable weight loss, regain time and z core
Preterm
15% weight loss is acceptable
Regain by 10-14days
loose Not more than -0.8 Z score. If lost more than that-> failure to thrive
Term
7-10% wt loss is acceptable
Regain by 7-10 days
when is nutr intervention appropriate in terms of weight regain by bbs
if baby hasn’t started to regain weight by day 5
First week of life: Who are the babies at risk?
these babies are at risk of not being able to regain their birth weight-> have to be monitored more closely
- C section mothers
- Multiple birth mothers
- Infants who have not latched on or nursed effectively for 12hrs
- Mothers of NICU infants
- Infants <37 weeks and less than 2.5kg
- Mothers with breast surgery
- Mothers with history of breastfeeding failure
- Antepartum mothers at risk of preterm delivery
what are the methods of assessing adequacy of feed?
- number of diapers
- frequency of feed, stool and peeing
- weight change before and after feed
Number of diapers as baby grows
for the first 6 days, baby should have as many diapers as days old
diaper should get heavier with urine each day, especially after day 3, as the supply of milk increases
once the baby is 6 days old: 6-8 soaked diapers per 24h
Size and frequency of stool
0-2 days: at least 1 stool per day
3+ days: 2-3 per day
after 4 weeks, the pattern of stool may change to 1 stool every 1-10 days
if baby’s stomach is soft, baby is happy and having 6-8 diapers every 24 hours, this small number of bowel movements is normal
stool should be about 2tbsp
when should baby stop loosing weight
stop at 4 days
once weight has been regained, what should the rate of weight gain be?
once the weight has been regained, babies should gain 25-30g on average per day over the next few months
stool color change
day 1-2: dark green or black (meconium)
day 3-4: brown, green or yellow
day >5: yellow
hunger cues
Early signs: stirring, rapid eye movement, suckling sounds, mouth opening, hand to mouth or suckling liking movements, rooting
Late: fussiness, irritability, exhaustion, sleep, crying (need to calm them down, otherwise it will help difficulty latching)
feed time and frequency
Newborns feed 8-12x da; Duration: 20-45 mins
Older babies may feed less frequently and for a shorter period of time as they become more efficient
good latch characteristics
Latch: wide-open mouth, the angle at the corner of the mouth between 130-150 degrees, corners of the mouth shouldn’t touch, chin is touching the breast, the head is tilted back, nose not touching the breast
when does volume of milk increase?
after 4 days
reasons for failure to thrive while breast feeding
Maternal causes:
- Poor let down and/or poor production
Infant causes:
- High energy requirement and/or low net intake and/or poor intake
Breastfeeding assessment questionnaire
• Ask these questions by day 5-7 of
birth
• If parents answer No to any of these questions, there is an issue with feeding
- Does baby have several bowel movements in 24 hours
that are mustard yellow with curds in them? - Does baby have 5-7 wet diapers in 24 hours?
- Do your breasts feel full before feeding and softer after
feeding? - If there’s been nipple soreness, has this been resolved?
- Do you hear swallowing when the baby is breastfeeding?
- Is the baby eating at least 8 times in 24 hours?
- Does the baby seem satisfied after a feeding?
- Is there a lack of sore, tender, or red and firm areas in
either breast? - Has the baby started gaining 1/2 - 1 ounce per day?
Signs that baby is drinking enough
- Wakes up on his own when hungry
- Feeds well and often (8 times or more per day, q 2-3hrs initially)
- Seems full after drinking
- Heavy diapers
- Gaining weight adequately
Signs that baby is not feeding enough
- Drowsy, sleepy and hard to wake up for feeding
- Less than 6 feeds per day
- Feeds less than 10 minutes, mom does not feed transfer
- Dark yellow urine, small amt of urine, orange stains in urine after the first 2 days
- Stool still has meconium, after the fifth day
- Less than 1 BM per 24hrs between 5 do. and 4 weeks
0-3 months feed recommendations and tips
- Exclusive breastfeeding or formula feeding
- Sterile feeding procedures to be done until 4mo/4moCGA
- Still requires feeding at night
- At 2 months, feeding progressively becomes shorter
- At 3 months,
- Baby tends to look around while nursing
- Baby start to sleep longer at night, transition from 8 to 6 feeds, however each baby is different
what to do when expressed milk is not available
If expressed breastmilk is not available, offer commercial infant formula that is prepared safely
supplements in breast-fed babies
Give a liquid vitamin D supplement of 400 IU (10 mcg) daily to infants who are fully or partially breastfed. Non-breastfed infants do not require a vitamin D supplement because infant formula contains vitamin D
give it to all infants or children younger than 2 years who are breastfed or receiving breastmilk until diet includes ≥400 IU per day of vitamin D from dietary sources
milestones: 1 month, 2 month, 4 month, 6 months
By 1 month:
• Sucks well on the nipple
By 2 months:
• Feeds every 2 to 4 hours during the day and may
need to feed during the night
By 4 months:
• Holds head steady when supported in a sitting position
At about 6 months, signs of developmental readiness for complementary foods:
• Has better head control
• Can sit up and lean forward
• Can let parent know when they are full (turns
head away)2
• Can pick up food and try to put it in their mouth
red flags 0-4 months
• Has < 6 wet diapers each day after 5 days
• Loses > 10% of birth weight within the first 2 weeks;
or by 2 weeks, does not regain birth weight or does not gain ≥ 20 g per day
• Consumes cow’s or goat’s milk (including pasteurized or
raw), plant-based beverages (soy, rice, almond),
evaporated milk or homemade formula
• Consumes water, juice, herbal teas or other liquids
• Introduces complementary foods too early (before infant
is showing signs of developmental readiness), including
adding cereal to a bottle
• Uses a propped bottle or infant is not supervised during
feeding
• Feedings are forced or restricted
• Skips feeds in attempts to facilitate longer sleep times
• Parent has depressive symptomatology in the early
postpartum period (may impact breastfeeding duration,
self-efficacy and increase breastfeeding difficulties)
red flags 6-9 months
• Does not consume iron-rich foods daily
• Consumes cow’s or goat’s milk or plant-based beverages (soy, rice, almond) as main milk source
• Consumes fruit juice, fruit drinks/punch, sports drinks, pop or beverages containing artificial
sweeteners or caffeine (coffee, tea, hot chocolate)
• Consumes raw or unpasteurized milk or milk products or unpasteurized juice
• By 9 months, lumpy textures have not been introduced or consumed
• Unsupervised during feedings
• Feedings are forced, restricted or infant is pressured to eat
what are infant formulas made of
based on cow milk
infant formula types, indication for use and notes
Cow’s milk-based
● Standard breastmilk substitute for healthy-term infants
Partially hydrolyzed cow’s milk-based
● Indications for use: None
● Contraindicated for infants with cow’s milk protein allergy
● No advantage over standard cow’s milk-based infant formulas on the digestive system
Lactose-free
● None
● Contraindicated for galactosemia, congenital lactase deficiency and cow’s milk allergy
Soy-based
Indications for use:
● Galactosemia
● Congenital lactase deficiency
● Cultural or religious reasons e.g. kosher
Notes:
● May consider for cow’s milk protein allergy if diagnosis for non-IgE-mediated cow’s milk protein allergy can be ruled out
Extensively hydrolyzed protein
● Physician-confirmed food allergies or malabsorption syndromes that cannot tolerate formula based on intact cow’s milk protein or soy protein
what is the most common food alergy in babies
cow milk
when is there cow milk allergy
• Usually occurs in babies younger than 1 year of age., will usually overcome is with age
2 types of milk allergy in babies
IgE mediated
Immediate reaction
Hives, rashes, wheezing, swelling in face, eczema, runny nose, vomiting, diarrhea
Start within minutes to 2 hours of ingestion of CMP
Non-IgE mediated (intolerance)
Delayed reaction
Itchy skin, eczema, colic, reflux, vomiting (large amount), mucus or bloody stools, poor wt gain
Within 48hrs to 1 week of drinking CMP
treatment for cow milk allergy in babies
cow free diet until 9-12 months
at what age can u give cow milk?
at 9-12 months
3.25% pasteurized milk only
not more than 750ml
when can u start giving solid foods?
4-6 months start introducing solids (iron rich foods are a priority)
what is the division of responsibility
parent decides what to give, child decides what to eat
dangerous of consuming more than 750ml of milk
iron anemia
what are the signs of readiness to feed
- Has good head and neck control
- Can sit without support
- Can lean forward and open mouth when interested
- Can turn head when uninterested in food or not hungry
- Can pick up food and try to bring it to his/her mouth
what should be the first foods to be introduced?
- Start with food rich in iron because their iron stores get used up
- No one food recommended as first, typically iron fortified baby cereal, but meat is also ok
how often should iron rich foods be consumed?
6-12 months: min 2x day
12months+: minimum 3 times a day
why is iron intake important for kids?
- Essential for neurodevelopment
- Baby have iron reserves until around 6 months old
- No iron in breastmilk
- Iron reserves may be even lower if mother was anemic or baby was born premature
what is the order for introducing solid foods?
- Once iron rich food introduced, no particular order to follow
- Do not introduce cow’s milk before 9-12 months
- Do not introduce dairy until good sources of iron are accepted
- When cow’ milk is introduced, give 3.25% milk
when should complimentary food be introduced to infants at no or low risk for food allergy,
or infants at no or low risk for food allergy, introducing complementary foods at about 6 months is recommended.
what are the characteristics of kids with high allergy risk?
Infants considered to be at high risk for allergic disease have either a personal history of atopy or a first-degree relative with atopy.
when should common allergic foods be introduced to kids at high risk?
For high-risk infants, and based on developmental readiness, consider introducing common allergenic solids at around 6 months of age, but not before an infant is 4 months of age.
when should breastfeeding be stopped?
Breastfeeding should be protected, promoted and supported for up to 2 years and beyond.
texture porgression
4-6 months: smooth puree
7-9 months: soft and finely chopped
12 months: small pieces, finger food
- Progress rapidly across textures as tolerated
- Wait 2-3 days before each new food
- Ensure that lumpy textures are offered no later than nine months. Encourage progress towards a variety of textures, modified from family foods (without added salt or sugar), by one year of age
Introduction of solids: How much?
- Start with 3-5ml (1/2 – 1 teaspoon)
- Increase to 15ml per serving (1 tablespoon) but for
- Initially not for nutrition oral development
- To develop oral and motor skills
- For exploration and experimentation
- Offer small amount at a time
breastfeeding:solids percentages across ages
0 to 6 months: 100% breast, 0% solid
6 to 8 months: 80 % breast, 20% solid
9 to 11 months: 50% breast, 50% solid
12 to 24 months: 30% breast, 70% solid
12-24 months milestones
- Growth slows compared with the first year resulting in decreased appetite and erratic and unpredictable food intake
- Unfamiliar foods are often rejected the first time
By 12 to 18 months:
• Acquires full chewing movements
By 24 months:
• Eats most foods without coughing and choking
• Eats most of the same foods as the rest of the family with some extra preparation to prevent choking
• Eats with a utensil with little spilling
• May only consume 4 or 5 well accepted foods
is canada food guide appropriate for toddlers?
1/2 plate of veggies-> not enough energy will be provided
toddlers require a lot of calcium and Vit D requirements-> canadian food guide is not sufficient
toddler feeding problems
- Excessive liquid intake, impeding acceptance of solid foods
- Grazing, unstructured mealtimes
- Prolonged feeding time (>30 minutes)
- Inadequate or immature oral-motor skills (unable to handle complex textures
- Sensory integration issues (will consume only foods of one color and/or texture)
Picky eaters behavioural strategies
- Offer liquids primarily between meals, and limit drinking during meals
- Encourage a structured and consistent schedule for 3 meals and 2-3 snacks daily
- Limit meals to 20-30 minutes
- Eliminating grazing behaviour on liquids and foods between meals
- Use a timer to have the child sit at the table for a finite period of time
- Offer food in a divided plate
- Offer 1 new or non preferred foods with 1 to 2 preferred foods
- Continue to offer non preferred food in a positive way
- Encourage exploration of a non preferred food (sensory)
- Establish a non-food reward system (for children older than 1 yo) were positive behaviour is praised
- Be as consistent as possible
- Encourage training and cooperation of all caregivers
- Encourage family mealtimes
- Provide age appropriate portions and developmentally appropriate texture
rate of weight and height change across ages
<1 y.o high weigh changes 5-10 y.o: decreased weight change rate
adolescence: weight and hight change speeds up
% of adult height gained during adolescense
15-20% of adult height is gained during adolescence
onset of growth spurt boys vs girls
Growth spurt starts later in
boys than girls with
higher peak velocity than in
girls
link between kcal and linear growth
Linear growth can be slowed or delayed if severely restricted in kcal or kcal expenditure is increased
% final ideal weight gained during adolescence
• 25-50% of final ideal weight is gained during adolescence
factros that affect timing and weight gain in teens
• Timing and amount of weight gain greatly affected by kcal intake and
expenditure
Changes in body composition and skeletal mass in teens: girls vs boys as well as timking
- Pre-pubertal, proportion fat and muscle for boys and girls are similar
- Normal % body fat is 23% in women and 15% in men post-adolescence
- ~45% of skeletal mass is added during adolescence
- By 20yo, 90% of total bone mass is gained
delayed puberty and bones
• Delayed puberty = failure to gain bone mass at normal rate and lower mineral bone density
• _ is one the environmental factors determining the onset of puberty
• Nutrition is one the environmental factors determining the onset of puberty
what is tanner scale used for?
assesses appropriate growth in adolescent period
shows at which age different maturations stages need to be achieved
what is there an opportunity for in teens?
It is the second-best window of opportunity to catch up with proper growth and development, if provided with adequate nutrition.
• Especially useful for handicapped children, delayed maturation stages can reflect possible malnutrition
True or False. The WHO growth charts for Canada can be used for children with special health care needs.
true
0-5 Years
percentiles and indicators to use to determine the following conditions
underweight, stunted, wasted, possible risk of overweight, overweight. obese
Underweight
Indicator: Weight-for-age
Percentile: <3rd
Stunted
Indicator: Length-for-age
Percentile: <3rd
Wasted
Indicator: Weight-for-length/BMI
Percentile: <3rd or <89% IBW
Possible Risk of Overweight
Indicator: Weight-for-length/BMI
Percentile: >85th
Overweight
Indicator: Weight-for-length/BMI
Percentile: >97th
Obese
Indicator: Weight-for-length/BMI
Percentile: >99.9th
- True or False. The 50th percentile is the goal for each child.
false
when to be concerned: Head circumferencefor-age (0-2 years)
below 3rd percentile and growing slowly
OR
above 97th percentile and growing rapidly
when to be concerned:
0 – 2 years
Weight-for-length or BMI
above 97th percentile
when to be concerned: 2-19 yo- bmi for age
above 97th percentile
