Pediatrics: Newborns and Infants Flashcards
Danger Signals: Failure to Thrive
Definition:
- weight for age falls below 3rd-5th percentile for gestation-corrected age and gender when plotted on appropriate growth chart (on more than 1 occasion)
- infants whose weight ↓ over ≥2 major percentile lines (90th, 75th, 50th, 25th, and 5th) = failure to thrive (FTT) ; ex: child at 50th percentile goes down to 5th percentile over a few months
- Use WHO growth chart until 2 yo, then CDC’s
In most cases in primary care, causes are usually:
- inadequate dietary intake
- diarrhea
- malabsorption (celiac, CF, food allergy)
- poor maternal bonding
- frequent infections
Danger Signals: Down Syndrome
- genetic defect caused by trisomy of chromosome 21 (3 copies instead of 2)
- Most common chromosomal ds
- avg lifespan is 60 yo
S/Sx
- round face that appears “flat” (↓ anterior-posterior diameter)
- upward-slanting eyes (palpebral fissures)
- low-set ears
- chronic open mouth d/t enlarged tongue (macroglossia)
- shorter neck
- short fingers
- small palms
- broad hand w/ transverse palmar crease (Simian crease)
NB:
- hypotonia
- poor Moro reflex
- Higher risk of intellectual disability
- congenital heart defects (50%)
- feeding difficulties
- congenital hearing loss
- thyroid disease
- cataracts
- sleep apnea
- early onset of Alzheimer’s ds (avg age 54 years)
Education:
- importance of cervical spine positioning
- monitor for myelopathic s/sx
- contact sports (football, soccer, gymnastics) may place higher risk of spinal cord injury
- avoid trampoline use unless under professional supervision
- Special Olympics requires specific screening for some sports
Danger Signals: Fetal Alcohol Syndrome
- AKA Fetal alcohol Spectrum Ds
Classic FAS facies:
- small head (microcephaly)
- shortened palpebral fissures (narrow eyes) w/ epicanthal folds
- flat nasal bridge
- thin upper lip w/ no vertical groove above upper lip (smooth philtrum)
- ears are underdeveloped
- can range from neurocognitive and behavioral problems (e.g., ADD to more severe intellectual disabilities)
- NO safe dose or time for alcohol during pregnancy
- Alcohol adversely affects CNS, somatic growth, and facial structure development
Danger Signals: Cryptorchidism
Undescended Testicle
- Empty scrotal sac(s)
- most cases involve undescended testicles
- 1-2 testicles may be missing
- Testis does NOT descent w/ massage of inguinal area
- Majority cases (90%) of cryptorchidism as a/w patent processus vaginalis
- Infant should be sitting and exam room should be warm to relax muscles when massage inguinal canal
- another option is to exam child after warm bath
- ↑ risk of testicular CA of testicles are not removed from abdomen
- surgical correction (orchiopexy) necessary within 1st year of life if testicle doe snot spontaneously descend
Danger Signals: Gonococcal Ophthalmia Neonatorum
- S/sx usually show within 2-5 days after birth
- infection can rapidly spread → blindness
- DO NOT delay treatment by waiting for culture results
S/Sx
- injected (red) conjunctiva w/ profuse purulent discharge
- swollen eyelids
Majority of cases are acquired during delivery (intrapartum)
- Coinfection w/ chlamydia is common
- any neonates w/ acute conjunctivitis presenting within ≤30 days from birth should be tested for chlamydia, gonorrhea, herpes simplex, and bacterial infection
Dx:
- Gram stain
- gonococcal culture (Thayer-Martin media)
- PCR for Neisseria gonorrhoeae, herpes simplex culture, Chlamydia trachomatis of eye exudate
→ Hospitalize and tx w/ high-dose IV or IM cefotaxime
- Preferred prophylaxis is topical 0.5% erythromycin ointment (1-cm ribbon per eye) immediately after birth
- Test and treat mother and sexual partner for STDs/STIs
Danger Signals: Chlamydial Ophthalmia Neonatorum (Trachoma)
- Sx shows in 4-10 days after birth
S/Sx
- edematous eyelids
- erythematous eyes w/ profuse watery discharge initially that later becomes purulent
When obtaining sample, collect not only exudate but also conjunctival cells
- R/O concomitant chlamydial PNA
Tx:
- systemic abx (e.g., PO erythromycin base or erythromycin ethylsuccinate QID x 14 days)
- only 80% effective
- may need 2nd course
- use only systemic abx
- Prophylaxis ointment used will NOT prevent neonatal chlamydial conjunctivitis or extraocular infections ► IMPORTANT for prenatal screening and treatment
** - Reportable disease
- Test and treat mother and sexual partner for STDs
Danger Signals: Chlamydial Pneumonia
- obtain nasopharyngeal culture for chlamydia
S/Sx
- frequent cough w/ bibasilar rales
- tachypnea
- hyperinflation
- diffused infiltrates on CXR
Tx:
- Erythromycin QID x 2 weeks
- Daily follow-up
**- Reportable disease
Danger Signals: Sudden Infant Death Syndrome
- a sudden infant death in apparently healthy infants <12 months
- cannot be explained after a thorough case investigation, including a scene investigation, autopsy, and review of clinical hx
RF:
- prematurity
- low birth weight
- maternal smoking and/or drug use
- poverty
Causes: multifactorial convergence of intrinsically vulnerable infant (genetic predisposition) during a critical development period w/ exogenous stressors
To ↓ risk:
- position infants on their backs (supine)
- use a firm sleep surface
- encourage breastfeeding
- routine immunizations
- room share without bedsharing
- offer a pacifier for sleep times
- avoid soft objects and loose bedding in sleep area
- avoid smoke exposure
- avoid overheating infant
Danger Signals: Excessive Weight Loss (>10%)
- NB expected to lose weight during the first few days of life
- Weight loss can vary by feeding method and delivery type
- Infants delivered by C-section tend to lose a larger % of birth weight than vaginally delivered babies
- Formula-fed infants may lose up to 5%
- breast-fed infants may lose 7-10%
Any lose should be regained within 10-14 days
- Weight loss beyond 10% in neonates is considered abnormal
- assess infant for dehydration, electrolyte disturbances, hyperbilirubinemia, and mother/infant for lactation difficulties
** Weight loss 7-10% starts after birth but should regain birth weight in 2 weeks
Danger Signals: Dehydration
- Signs of severe dehydration:
- > 10% weight lose
- weak and rapid pulse
- tachypnea or deep breathing
- parched mucous membranes
- anterior fontanelle markedly sunken
- skin turgor showing tenting
- cool skin
- acrocyanosis
- anuria
- change in LOC (lethargy to coma)
→ Refer severely dehydrated infants to ED for IV hydration
- Severe dehydration d/t/ acute gastroenteritis is one of the leading causes of death of infants in developing world
Skin lesions: Congenital Dermal Melanocytosis
Mongolian Spots
- Most common type of pigmented skin lesions in NB
- present in almost all Asians (85-100%), >50% of Native American, Hispanic, and Black neonates
- Blue- to black-colored patches or stains
- common location: lumbosacral area, but can be anywhere on body
- may be mistaken for bruising or child abuse
- usually fade by 2-3 years
Skin lesions: Milia
Miliaria, or “Prickly Heat”
- most common in neonates
- multiple 1- to 2-mm papules located mainly on forehead, cheeks, and nose
- d/t retention of sebaceous material and keratin
- resolves spontaneously
Skin lesions: Erythema Toxcum Neonatorum
- Small pustules (whitish-yellow color), 1- to 3-mm in size
- surrounded by red base
- erupt during 2nd-3rd day of life
- located on face, chest, back, and extremities
- last from 1-2 weeks and resolves spontaneously
Skin lesions: Seborrheic Dermatitis
“Cradle Cap”
- Excessive thick scaling on scalp of younger infants
- treated by softening and removal of thick scales on scalp after soaking scalp a few hours (to overnight) w/ vegetable oil or mineral oil
- shampoo scalp and gently scrub scales w/ soft comb
- prevention is by frequent shampooing w/ mild baby shampoo and removing scales w/ soft brush/comb
- self-limited condition, resolves spontaneously within few months
Skin lesions: Faun Tail Nevus
- Tufts of hear overrlying spinal colum usually at lumbosacral area
- may be sign of neural tube defects (spina bifida, spina bifida, occulta)
- perform neuro exam on lumbosacral nerves (fecal/urinary incontinence, problems w/ gait)
- Order US of lesion to R/O occult spina bifida
Skin lesions: Cafe Au Lait Spots
- Flat light-brown to dark-brown spots >5 mm (0.5 cm)
- If ≥6 spots >5 mm (0.5 cm) in diameter are seen → R/O neurofibromatosis or von Recklinghausens’ ds (e.g., neurologic ds marked by seizures, learning disorders)
→ Refer to pediatric neurologist if spots meet the same criteria to R/O neurofibromatosis
Skin lesions: Vascular Leions - Salmon Patches
Nevus Simplex
- aka “stork bites” or “angel kisses”
- flat pink patches found on forehead, eyelids, and nape of neck
- usually appear on both sides of midline (e.g., on both eyelids or across entire nap of neck)
- blanchable but color changes w/ crying, breathing holding, and room temp changes
- Consider Beckwith-Wiedemann or FAS if glabellar lesion seen
- Typically fade by 18 months
Skin lesions: Vascular Lesions - Port Wine Stain
Nevus Flammeus
- pink-to-red
- flat
- stain like lesions located on upper and lower eyelids or on V1 and V2 branches of trigeminal nerve (CN V)
→ Referred to pediatric ophthalmologist to R/O congenital glaucoma
- blanches to pressure
- irregular in size/shape
- usually unilateral
- large lesions located on half of the facial area may be sign of trigeminal nerve involvement and Sturge-Weber syndrome (rare neurologic ds)
- lesions do NOT regress and grow w/ child
- lesions can be treated w/ pulse-dye laser (PDL) therapy
Skin lesions: Vascular Lesions - Hemangioma
Strawberry Hemangioma
- raise vascular lesions ranging in seize from 0-.5 - 4.0 cm
- bright red
- feels soft to palpation
- usually located on head of neck
- lesions often grow rapidly during first 12 months of life but majority will involute gradually over the next 1-5 years
- watchful waiting is usually strategy
- can be tx w/ PDL therapy
Vision Screening: NB Vision
- NBs are nearsighted (myopia) and have a vision of 20/400
- can focus best at a distance of 8-10 inches
- during first 2 months, infant’s eyes may appear crossed (or wander) at times (normal finding)
- if one eye is consistently turned in/out, refer to pediatric ophthalmologist
- human face is preferred by NB
- NBs do NOT shed tears because lacrimal ducts are not fully mature at birth
- Caucasian neonates are born w/ blue-gray eyes; normal for their eye color to change as they mature
- Retinas (CN II) are immature at birth and reach maturity at age 6 years
Vision Screening: Infant Screening
1. 1 month
2. 3 months
3. 6 months
4. 12 months
5. Retina and optic disc
- infant can fixate briefly on mother’s face; prefers human face
- infant will hold hands close to face to observe them; hold a bright object or a toy in front of the infant; watch behavior as the infant fixates and follows toy for a few seconds
→ avoid using object/toys that make noises when testing vision - Makes good eye contact
- turns head to scan surroundings w/ 180º visual field - makes prolonged eye contact when spoken to
- will actively turn head around 180º to observe people and surroundings for long periods
- recognizes self in a mirror and parents and fav people from a longer distance - Set fundoscope lens at 0 to -2 diopeters
- fundus appears dark orange to red (red reflex)
- red reflex of both eyes should be symmetrical in shape and color
- Set fundoscope lens at 0 to -2 diopeters
Vision - Abnormal Findings: Strabismus
- Misalignment of the eye
- Horizontal strabismus may be esotropia or exotropia
- Vertical strabismus may be hypertropia or hypotropia
- Uncorrected strabismus can result in permanent visual loss and abnormal vision such as diplopia
Tx:
- eyeglasses
- eye exercise
- prism
- eye muscle surgery
Esotropia
inward turning of the eyes
Exotropia
Outward turning of the eyes
Hypertropia
one one higher than the other
Hypotropia
one eye lower than the other
Diplopia
double vision
Vision - Abnormal Findings: Amblyopia
“Lazy eye”
- If corrected early, affected eye can have normal vision
Vision - Abnormal Findings: Esotropia
- misalignment of one or both eyes (“crossed-eye”)
- Infants (<20 weeks) may have intermittent esotropia, which usually resolves spontaneously
- some infants with obvious epicanthal folds appear “cross-eyed” (pseudostrabismus), but corneal light reflex will be normal
→ Refer to pediatric ophthalmologist if in doubt
Vision - Abnormal Findings: Indications for Referral
- Abnormal red reflex (R/O retinoblastoma, cataract, glaucoma)
- Presence of white reflex (R/O retinoblastoma)
- Strabismus (R/O CN III, IV, and VI abnormalities, retinoblastoma)
- > 2-line difference b/w each eye
- Esodeviation presents after 3-4 months of age
- Corneal light reflex test w/ abnormal results
- Shape/appearance of pupils not equal
- New onset of strabismus (e.g., retinoblastoma, brain mass, bleeding, lead poisoning)
Vision - Abnormal Findings: Red Reflex
- Screening test for cataracts and retinoblastoma
- abnormal if there are white-colored opacities (cataracts) or white spots (leukocoria)
- determine presence of white reflex → R/O retinoblastoma
→ Refer to infant/pediatric ophthalmologist ASAP - Even if test is normal during visit, but parent reports that one eye appears white on a digital photograph → Refer
- If absence or ↓ intensity of red reflex, R/O cataract and refer to pediatric ophthalmologist
Procedure:
- Perform test in a darkened room
- use a direct ophthalmoscope and shine light about 12-18 inches away from the infant
- Normal finding is symmetrical and round orange-red glow from each eye
Vision - Abnormal Findings: Congenital Cataracts
- Red reflex exam on neonate shows a round, white-colored pupil
Vision - Abnormal Findings: Hirschberg Test
Light Reflex Test or Corneal Light Reflex
- Screening test for strabismus
- abnormal if corneal light reflex is not clear or if it’s “off-center”
Procedure:
- Shine light directly in eyes (24 inches away) using a fixation target
- Infant or child must look directly forward w/ both eyes aligned
- Observe for the symmetry and brightness of light reflecting from both eyes
Hearing Screening: Universal screening
Universal screening for hearing loss is done while in nursery before discharge
Hearing Screening: Newborns
- Each state has its own rules about neonatal hearing exams
Hearing Screening: Auditory Brainstem Response
- ;Measures CN VIII by use of “click” stimuli
Hearing Screening: Otoacoustic Emissions
1. Gross hearing test
- as a response to loud noise, look for startles response (neonates), blinking, turning toward sound
- measures the middle ear mobility only
- less sensitive than auditory brainstem response (ABR)
Hearing Screening: Mnemonic Device (HEARS) for High-risk factors for Hearing loss
H - Hyperbilirubinemia
E - Ear infections (frequent)
A - Apgar scores low at birth
R - Rubella, cytomegalovirus (CMV), toxoplasmosis infections
S - Seizures
Premature infant sand infants admitted to NICUs have a higher incidence of hearing loss compared w/ full-term infants
Infant Lab Tests: Lab drawing techniques
- testing varies from state to state
- blood is obtained by heel stick or from cord blood
- a spot of blood is blotted into filter paper for stable transport
Infant Lab Tests: Thyroid-Stimulating Hormone
- federally mandated
- Lack of thyroid hormone results in mental and somatic growth retardation
- treated by thyroid hormone supplmentation
Infant Lab Tests: Phenylketonuria
- PKU testing is federally mandated
- severe intellectual disability results if not treated early
- inability to metabolize phenylalanine to tyrosine d/t defect in production of enzyme phenylalanine hydroxylaze
- Perform test only after infant has protein feeding (breast milk or formula) for at least 48 hours
- higher risk of false negatives if done too early (<48 hours)
Tx:
- following special diet (phenylalanine-free diet)
Infant Lab Tests: Sickle Cell Disease
- Required test can detect 4 types of hemoglobin: F, S, A, and C
Infant Lab Tests: Hemoglobin and Hematocrit
- normal NB have Hgb F (fetal hemoglobin) and Hgb A
- healthy term infants have enough iron stores to last up to 6 months
- screening for anemia is done in late infancy (9-12 months) for healthy full-term infants
- Not screened at birth because hemoglobin is ↑ from maternal RBCs mixed in fetal RBCs
Infant Lab Tests: Lead Screening
- high-risk children (e.g., children living below poverty level or living in homes built prior to 1978) should be screened at 1-2 years (12 and 24 months)
Nutritional Intake: what is preferred for babies?
Breastfeeding is preferred over formula
- If formula chosen, start w/ one fortified w/ iron
Breastfeeding
1. Give what vitamin w/breastfeeding?
2. How many calories per ounce?
3. Why breastfeeding?
- Give Vit D drops (400 IU of vit D) starting in first few days of life if breastfeeding because breast milk alone does not provide adequate levels of vit D
- Infant formula is supplemented w/ Vit D, iron, other vitamins, and essential fatty acids - Breast milk or formula contains 20 calories/ounce
- ↓ risk of infections (e.g., otitis media) during the first few weeks of life
Breastfeeding: Colostrum
- Sticky and thick
- yellowish fluid that comes before breast milk
- Secreted first few days after birth
- contains large amounts of maternal antibodies and nutrients (IgG antibodies)
Nutritional Intake: Cow’s Milk
- Avoid cow’s milk the first year of life (causes GI bleeding)
- Common cause of iron-deficiency anemia in babies and young children
Nutritional Intake: Solid Foods
- Recommended to wait until 4-6 months for complementary foods
- start w/ a single-grain, iron-fortified baby cereal, mix w/ 4 tablespoons of breast milk/formula
- serve 1-2 a day after bottle or breastfeeding
- avoid feeding only rice cereal d/t possible exposure to arsenic
- Introduce one food at a time for 405 days (if allergic, easier to identify offending foods)
Elimination: Meconium
- thick dark-green to black-colored stool, odorless
- most full-term neonates pass meconium stool within a few hours of birth
- Failure to pass meconium within 24 hours of birth is worrisome
- may be a sign of intestinal obstruction, Hirschsprung’s disease, or cystic fibrosis
Head Findings: Caput succedaneum
- Caput succedaneum is diffused edema of scalp that crosses the midline
- Caused by intrauterine and vaginal pressure from prolonged or difficult vaginal labor
- scalp becomes molded and “cone-shaped”
- self-limited and resolves spontaneously
** Caput succedaneum crosses midline and cephalohematoma does not (blood blocked byu scalp sutures)
Head Findings: Head Circumference
AKA occipitofrontal circumference (OFC)
- use paper tape (cloth tape stretches) and place above the ear
- Avg head circumference at birth is 13.7 inches (35 cm)
- Head circumference is measured at each wellness visit until 36 months (3 years)
- In NB, chest is about 1-2 cm smaller in size than head circumference
- head circumference will ↑ by 12 cm during first 12 months
- fastest rate of head growth is during first 3 months os life (2 cm/month)
Abnormal Head Finding: Cephalohematoma
- Traumatic subperiosteal hemorrhage
- R/O skull fracture
→ Order radiographs of skull
- swelling does NOT cross the midline or suture lines
Weight Gain and Length: Birth Weight
- Neonates lose up to 10% of body weight but should regain it by 2 weeks of age
- double their birth weight by 6 months
- triple their birth weight by 12 months
Weight Gain and Length: Infant Weight
1. 0-6 months
2. 6-12 months
- 6-8 ounces/week and 1 inch per month
- 3-4 ounces/week and 1/2 inch per month
If child’s weight and/or length decelerates across ≥2 major percentiles, R/O FTT
- any child who is at 3rd-5th percentile is considered to have FTT
- Of many causes of FTT, the most common in primary care are undernutrition and malnutrition
- Evaluate child, but do not forget to assess maternal bonding and depression
Length and Height
Length (linear growth) of infants is measured from birth to ~24 months
- starting at 2 years, measure height (child is standing up)
- calculate BMI
- plot measurements on infants/child’s percentile growth chart
Dentition: First Teeth
1. S/Sx
2. 6-10 months
3. 2.5 yo
Primary teeth
Both left and right teeth erupt bilaterally at the same time (symmetrical)
- symptoms are drooling, chewing on objects, irritability, crying, and low-grade fever
- lower central incisors (lower front teeth)
- Has complete set of primary teeth (20 teeth)
- Will typically lose teeth in same order that they erupt
Dentition: First Permanent Teeth
Deciduous Teeth
@ 6 years of age
- shed central incisors
- first permanent teeth to erupt are upper and lower first molars
Genitourinary Anomalies: Hypospadias
Urethral meatus located on ventral aspect of penis
- location may be at the glans or shaft
- some have 2 urethral openings → one opening is normal and other is lower on the glans/shaft → Refer to pediatric urologist
- Urethral opening under glans/shaft
Genitourinary Anomalies: Epispadias
Urethral meatus is located on dorsal aspect (upper side) of penis
- Urethral opening on top of glans/shaft → Refer to pediatric urologist
Genitourinary Anomalies: Hydrocele
Presence of fluid inside scrotum (tunica vaginalis/processus vaginalis) resulting in swelling of affected scrotum
- skin is normal color and temp
- fairly common in NB males
- Incidence is 10-20 causes/1,000 live births
Transillumination - affected testicle(s) will show ↑ size in the “glow” of light compared w/ normal scrotum
- darken room and place light source on scrotal skin
- compared each scrotum
* Used to asses for hydrocele, empty scrotal sac, and scrotal masses
- Infant w/ hydrocele and transillumination → Scrotal sac w/ hydrocele will appear “brighter” or will have more light glow compared w/ scrotum w/ a testicle (solid objects block light, so less glow of light)
Genitourinary Anomalies: Genitourinary Anomalies: Newborn Female vagina swollen w/ small amount of blood-tinged discharge
Caused by withdrawal of maternal hormones
- disappears within a few days
Genitourinary Anomalies: Cryptorchidism
- Retention of 1-2 testicles in abdominal cavity or inguinal canal
- markedly ↑ risk of testicular CA and infertility
- Order inguinal and abdominal US
- corrected surgically before 12 months of age
→ Refer to pediatric urologist for eval b/w 6-12 months of age
Epstein’s pearls
White papules found on gum line resembling an erupting tooth
Reflex Testing: Anal Wink
Gently stroke anal region
- Look for contraction of perianal muscle
* Absence is abnormal → suggestive of lesion on spinal cord (e.g., spina bifida)
Reflex Testing: Plantar Reflex
Babinski Reflex
- Upward extension of big toe w/ fanning of the other toes
- Starting on heel, stroke firmly the outside of the sole toward front of foot
Reflex Testing: Palmar Reflex
Grasp Reflex
- Place finger on infant’s open palm
- infant closes its hand around finger
- Pulling away the examiner’s finger causes infant’s grip to tighten
Reflex Testing: Moro Reflex
Startle Reflex
- Sudden loud noise will cause symmetric abduction and extension of arms followed by adduction and flexion of arms over body
- disappears by 3-4 months
Absence on one side → R/O brachial plexus injury, fracture, or shoulder dystocia
Absence on both sides → R/O spinal cord or brain lesion
Older infant: Persistence of Moro reflex is abnormal → R/O brain pathology
- A strong Moro reflex in an older infant (≥6 months) is abnormal and indicative of brain damage
Reflex Testing: Step Reflex
- Hold baby upright and allow dorsal surface of one foot to touch the edge of a table
- Baby will flex the hip and knee
- place stimulated foot on tabletop (stepping motion)
Absent w/ paresis and breech births
- Disappears by 6 weeks
Reflex Testing: Blink Reflex
- Eyelids will close in response to bright light or touch
Reflex Testing: Tonic Neck Reflex
Fencing Reflex
- Turning head to one side w/ jaw over shoulder causes arm and leg on same side to extend
- arm and leg on the opposite side will flex
Reflex Testing: Rooting Reflex
Stroke corner of mouth causes baby to turn toward stimulus and suck
- disappears by 3-4 months
Mumps, Measles, and Rubella (MMR) and Varicella Vaccine
- Live attenuated virus
- NOT recommended before 12 months (no effective d/t immature immune system)
- If dose given before 12 months, must be repeated!
- Avoid salicylates for 6 weeks (theoretical risk of Reye’s syndrome)
- Children age birth-12 years should NOT be given any aspirin or aspirin products (e.g., Pepto-Bismol, Paprin, Alka Seltzer, Kaopectate)
1st dose: 12 months
2nd dose: 4-6 years (preschool age)
Prof of varicella: chickenpox hx or herpes zoster on chart y healthcare provider
- record of 2 doses
- or positive varicella titer
Influenza vaccine
- Since 2016-17, CDC recommends injectable flu vaccines; nasal spray form is not to be used (live attenuated influenza vaccine)
- Do not give influenza vaccines before 6 months; not effective d/t immature immune system
- takes 2 weeks to produce antibodies after vaccination
- Recommended for anyone ≥6 months (with rare exceptions)
Esp for people w/:
- children 6 months-4 years
- congenital heart disease
- asthma
- cystic fibrosis
- sickle cell anemia
- heart disease
- COPD
- pregnant women during flu season
- Native Americans/Alaskan natives
- healthcare personnel
- elderly
- Trivalent inactivated influenza vaccines (protect against 3 types of influenza viruses)
- Minimum age: 6 months → give fall to winter as injection
- Quadrivalent influenza vaccines (protects against 4 types of influenza viruses)
Influenza vaccine Contraindications
- Age <6 months
- Severe egg allergy
→ If hives only, can receive flu vaccine
→ but IF severe reaction to eggs (hypotension, wheezing, N/V) requiring med tx or epinephrine, pt can only receive flu vaccinee in Output or Inpt clinic that has provider who can tx anaphylaxis (e.g., epinephrine, intubation, O2) - Mod-severe illness w/ fever (wait until pt is better)
- Hx of Guillain-Barre syndrome (GBS)
Live Influenza Nasal Spray (FluMist)
- Use of live influenza nasal spray (FluMist); recommendations change annually
Avoid in:
- Children < 2 years
- Children 2-4 ys w/ wheezing within past 12 months
- Child w/ other underlying conditions predisposing them to influenza complications → use inactivated form of flu vaccine (injection form)
- Use inactivated injection form of flu vaccine
Diphtheria, Tetanus, Pertussis Vaccines (DTaP)
- has fewer side effects than older DTP form
- Diphtheria-tetanus (DT) → used for infants and children < 7 years unable to tolerate pertussis component
-Tdap: For ≥7 years
- at 11-12 → give Tdap
- Or if due for tetanus booster, give Tdap once in a lifeetime
- Then Td (tetanus diphtheria) Q10 years for lifetime
- If incomplete TDaP series and children ≥ 7 years, give Tdap instead
- can be given to pregnant and breastfeeding mothers
- Tdap given to children <7 years is NOT valid (use DTaP)
Side Effects: DTaP/DT
+ Contraindications
+ Precautions
+ Not considered contraindications
- fever (100.4ºF), up to 50% of pts
- Swelling, pain, and/or redness at injection site, up to 50% of pts
- Irritability in up to 50% of pts
- Acute encephalopathy (1/110,000)
Contraindications:
- Severe allergic reactions
- Encephalopathy (e.g., prolonged seizures, changes in LOC not attributed to another cause within 7 days of vaccine administration)
Precautions:
- Fever ≥105.0 º F w/in 48 hrs of dose
- Seizures w/in <3 days of last dose
- Collapse or shock-like state w/in 48 hrs of last dose
Not considered contraindications:
- Fam hx of seizures
- Fam hx of SIDS
- Fever <105ºF from prior DTaP vaccine
Vaccine Adverse Event Reporting System
- national postmarking vaccine safety surveillance program in US managed by both CDC and FDA
- report vaccine adverse events
Immunization Tips:
By 15-18 months, the following vaccines are usually completed for most infants:
- Hep B vaccine (3 doses)
- Haemophilus influenzae type b (Hib) vaccine (several types of Hib vaccines; may required 2, 3, or 4 doses)
- Pneumococcal vaccine (PCV 13, 4 doses)
- Rotavirus vaccine (2-3 doses)
- Hep A (HepA; 2 doses)
Which vaccine is only given at birth?
Hepatitis B
- If Hep B surface antigen (HBsAg)-positive mother, give neonate hepatitis B immunoglobulin (HBIG) and Hep B vaccine
If ≥7 years, which vaccine to use? DTaP or Tdap?
When to give Tdap as booster?
Do NOT use DTaP if ≥ 7 years; use Td or Tdap.
Give Tdap vaccine at 11-12 as booster. If older, then replaced 1 dos of Td w/ Tdap (once in a lifetime)
When should you give MMR and varicella?
Do NOT give before 12 months.
What is the youngest age for influenza vaccine?
6 months
Exam Tip: What may not appear on exam regarding vaccine timelines?
any vaccine that has a time range does not appear on exam
Ex:
- 3rd dose of inactivated polio (IPV) can be given from 6-18 months
- 3rd dose of Hep B can be given b/w 6-18 months
- Vaccine table here only contains childhood vaccines that must be given by a definite age (no “wiggle” room)
Growth and Development: Newborns
- Strong primitive reflexes (e.g., Moro, rooting, fencing)
- Head lag
- Grasps finger tightly if placed on baby’s hand (grasp reflex)
- Seedy yellow stool after each feeding (if breastfed)
- Eats Q2-3 hrs or nurse 8-10 x daily
- Does not produce tears when crying; tear ducts are not mature at birth
- Sleeps 16 hrs daily
- Report high-pitched cry, “catlike” cry → hypotonic microencephaly
Growth and Development: 2 months
- follows objects past midline
- Coos vowels (e.g., “aa”) and makes gurgling sounds
- lifts head 45º when prone
- Smiles in response to another
Growth and Development: 4 months + Fine/Gross Motor Skills
- Smiles spontaneously (social smile)
- Begins to babble
Fine Motor:
- Brings hands to mouth
- Can swing by dangling toys
Gross Motor:
- Holds head steady and unsupported
- Rolls from front to back (supine to prone)
Growth and Development: 6 months + Fine/Gross Motor Skills + language
what to report?
Fine Motor:
- has palmar grasp of objects
- Reaches for toys using palmar grasp
- Brings things to mouth
- Starts to pass things from one hand to the other
Gross Motor:
- Begins to sit up independently w/out support
- Rolls over in both directions (back/supine to stomach and stomach to back/supine)
Language:
- Starts to say consonants (e.g., “da-da,” “ba-ba”)
- Is very curious and will look around environment
Report failure to follow objects pas midline (180º), poor eye contact
Growth and Development: 9 months + Fine/Gross Motor Skills + Language
Fine Motor:
- Pincer grasp starts and can pick up things (e.g., food) b/w thumb and forefinger
- waves “bye-bye”
- May clap hands and play clapping games (e.g., pat-a-cake)
Gross Motor:
- Pulls self up to stand
- Crawls and “cruises”
- Bears weigh well
Language:
- Plays peek-a-boo
- “stranger anxiety” very obvious
Report absence of babble, inability to sit alone, strong primitive reflexes such as Moro (startle reflex) or fencing (tonic neck reflex)
Growth and Development: 12 months + Fine/Gross Motor Skills + Language
Fine Motor:
- can use “sippy” cup
Gross Motor:
- stands independently
- May walk independently
- starts to cruise (moves from one piece of furniture to the next for support)
Language:
- can say 1-2 words other than repetitive sounds (e.g., mama, dada)
- can say exclamations, such as “uh oh!”
- knows first name
Other:
- Growth rate slows down
- Follows simple directions such as “pick up toys”
- report absence of weigh bearing, inability to transfer objects hand to hand
Growth and Development: 15 months + Fine/Gross Motor Skills + Language
Fine Motor:
- feeds self w/ spoon
- can drink from a cup
Gross Motor:
- Walks independently for longer distances
Language:
- follows commands w/ gestures
- vocabulary of 4-6 words
Growth and Development: 18 months + Fine/Gross Motor Skills + Language
Fine Motor:
- Turns pages of book
Gross Motor:
- Can walk up steps
Language:
- Can point to 4 body parts
- Vocab of 10-20 words
Safety Education
- Advise pt to learn infant CPR/BLS
- Avoid heating formula in microwave
- Do not leave baby on changing station (e.g., to answer phone)
- Do not position cribs next to strings/cords → when child is crawling, hide electrical cords
- Close toilet seats (safety locks); lock bathroom doors; lock cabinets w/ cleaning products
- Turn pot handles away from edge of stove; use rear burners on stove
- Use safety locks for stove handles, low cabinets and doors
Choking prevention
- Remove objects smaller than 2 inches
- Cut up foods into smaller pieces (e.g., hot dogs, carrots, grapes)
Examples of choking sources:
- grapes
- raw carrots
- hot dogs
- latex balloons
- coins
- buttons
- Avoid giving hard candy to children <6 years
- Encourage at least 1 parent to attend infant/child BLS course
Car Safety
- Infants and toddlers up to 2 years should be in rear-facing car seat
- Safest plan in car for infant/child <13 years is back seat
- Avoid used infant safety seat if its parts are missing or damaged
- Air bags in cars can cause serious brain injury if they hit child’s head or neck area
- Turn off air bag on front seat if person who is using seat is under weight limit; usually set at 100 lb (check car manual)
Car Safety Seats: Infants and toddlers
Type of seat:
- Rear-facing care seat w/ harness system until 2 years
- convertible car seats can be used as rear- and front-facing car seats
Notes:
- Children <2 years are 75% less likely to be killed or injured in car crash if they are in rear-facing seat
Car Safety Seats: Toddler-Preschool
Type of Seat:
- Safest if rear-facing seat up to 2 years
- forward-facing care seat w/ harness system
- Weight-limit ranges from 80-100 lb (depends on brand)
Notes:
- Children ≥2 years (or if over the weight/height limit for rear-facing car seat) until they have reached weight limit
Car Safety Seats: School age
Type of seat:
- Booster seats (belt-positioning booster seats)
Notes:
- Use until child has reached 4’9” or is 8-12 years
- Shoulder belt should cross middle of child’s chest/shoulders
Car Safety Seats: Older child - teenager
type of seat:
- seat belt w/ lap belt
Notes:
- All children ≤13 years should sit in back seat and use seat belt w/ lap belt
Toxic Exposures
chronic exposure to second-hand smoke ↑ risks for:
- SIDS
- otitis media
- bronchitis
- pneumonia
- wheezing
- coughing
- Also affects lung development and exacerbates asthma
Jaundice (hyperbilirubinemia)
1. Definition/Etiology/Pathology
- elevation d/t ↑ breakdown of fetal RBCs exceeding infant’s liver capacity to conjugate bilirubin
- Free, unbound, unconjugated bilirubin (breakdown product from old RBCs) is toxic to cells and can be deposited in tissue (e.g., brain, nerve cells) → necrosis
- ↑ conjugated hyperbilirubinemia may indicate underlying ds but is NOT toxic to CNS
Pathologic:
- Jaundice w/in first 24 hrs of life → ALWAYS pathologic!
- Evaluate for sepsis, congenital TORCH infections, occult hemorrhage, or erythroblastosis fetalis
- Caucasian infant’s color is yellow/orangish tinge or soles of feet are yellow
- jaundice more difficult to detect visually in infants w/ darker skin, so blood tests should be done
Jaundice of full-tern infant after 2 weeks of age:
- Requires evaluation → consider sepsis, hemolytic ds, metabolic ds, intestinal obstruction
- Bilirubin level ↑ too rapidly (>5 mg/dL daily)
- Total bilirubin levels >17 mg/dL
Nonpathologic:
- Physiologic and breastfeeding jaundice most common
- Consider breast milk jaundice if full-term exclusively breastfed infant w jaundice after 3 weeks of age
Jaundice (hyperbilirubinemia): Physiologic Jaundice
AKA neonatal unconjugated hyperbilirubinemia or neonatal icterus
- jaundice appears when bilirubin level is ≥ 5 mg/dL
- Jaundice first appears on head/face (sclera is yellow) and progresses down to chest, abdomen, legs, and soles o feet
- Caucasian infant’s color is yellow or orangish tinge, or soles of feet are yellow
- Jaundice more difficult to detect visually in darker skin, so blood tests should be done
- usually starts after 24 hrs and will usually clear up within 2-3 weeks
- total bilirubin levels in Caucasians and African American infants can peak at 7-9 mg/dL, but Asian infants have higher peak values (10-14 mg/dL)
Jaundice (hyperbilirubinemia): Breast Milk Jaundice
- onset is later than physiologic jaundice
- usually starts to show after 4-5 days of life
- peaks at 7-14 days
- can take >1 month to clear
- thought to be caused by a substance in breast milk that inhibits hepatic conjugation of bilirubin
- bilirubin levels may exceed 20 mg/dL
- often a brief (12-hr) period of breastfeeding cessation w/ pumping to maintain milk supple and fluid and caloric supplementation for infant will ↓ bilirubin levels enough to resume breast milk as sole nutritional source
- some infants will also need phototherapy
Jaundice (hyperbilirubinemia): Breastfeeding Jaundice
- in contrast to breast milk jaundice, this is actually downstream sequelae of poor intake of calories and failure to produce stool
- can also occur in bottle-fed infants w/ poor intake (less common)
Jaundice (hyperbilirubinemia)
2. Treatment Plan
- Check bilirubin level; use noninvasive methods first (transcutaneous bilirubin testing)
- If suspect pathologic jaundice, order serum fractionated bilirubin level, Coombs test, CBC, reticulocyte count, and peripheral smear
- Med intervention usually not needed unless total bilirubin levels are approaching or exceeding hour-specific values on a risk-based nomogram
- Keep baby well-hydrated w/ breast milk or formula → feed infant Q2-3 hrs (10-12x daily)
- Check bilirubin level; use noninvasive methods first (transcutaneous bilirubin testing)
First-line tx: Phototherapy
- light in blue spectrum is most effective wavelength
- Skin converts bilirubin into nontoxic water-soluble form so it is excreted in urine
- All newborns should be seen for follow-up within first 5 days of life to check for jaundice
Jaundice (hyperbilirubinemia)
3. Complications
- Bilirubin encephalopathy/kernicterus:
- neurologic ds caused by high levels of unbound bilirubin in circulation, damages infant’s CNS
- associated w/ severe intellectual disability and seizures
Physiologic Anemia of Infancy
- Hgb ↓ at lowest level in life (nadir) at 8-12 weeks of age
- Full-term infants’ hgb ↓ to 9-11 g/dL
- # of Hgb ↓ after birth d/t ↑ in oxygen availability and ↓ in erythropoietin production by kidneys
- When hgb is at the lowest, O2 needs exceed body’s ability to deliver it → stimulating erythropoietin production and RBC production from bone marrow
Congenital Lacrimal Duct Obstruction (Dacryostenosis)
1. Definition/Etiology
2. Clinical Presentation
3. Treatment
4. Complication(s)
- AKA congenital nasolacrimal duct obstruction
- occurs in approx 6% of newborns
- usually resolves spontaneously w/in 6 months in majority of infants (90%)
- AKA congenital nasolacrimal duct obstruction
- Infant’s mother c/o infant having:
- persistent tearing
- eyelash matting in morning on 1-2 eyes
- no conjunctival erythema
PE
- when lacrimal duct is palpated, reflux of mucoid discharge or tears may be seen
- yellow- to green-colored purulent eye discharge is abnormal in absence of other signs of infection → R/O acute dacryocystitis
- can occur w/ chronic dacryostenosis
- suggestive of bacterial overgrowth in lacrimal sac
- short course of topical antibiotics can be beneficial if copious or extremely bothersome
- Lacrimal sac massage/compression → place clean finger on lacrimal sac, apply moderate downward pressure over lacrimal sac for 2-3 secs; perform maneuver 2-3 x daily
- short course of topical antibiotics can be beneficial if copious or extremely bothersome
- Acute Dacryocystitis
- Look for redness, warmth, tenderness, and swelling in 1 of lacrimal ducts
- occurs commonly w/ dacrocystoceles
- culture discharge
- tx w/ systemic antibiotics for 7-10 days to prevent complications of preseptal or orbital cellulitis
- usually caused by streptococcal or staphylococcal organisms
infant Colic (Rule of 3s)
- Goal when evaluating infant w/ colic is R/O conditions causing pain/discomfort, infections, environmental, and formula “allergy”
Rule of 3’s
- Crying for no apparent reason lasting ≥3 hrs/daily in infant <3 months; crying usually occurs at same time each day
- Crying occurs >3 days a week
- Excessive crying usually resolves by 3-4 months
Coarctation of the Aorta
1. Definition/Etiology
2. Screening/S&Sx/Labs
3. Older Infants (Normal vs abnormal)
- Congenital narrowing of a portion of aorta
- most commonly coarctation is distal o subclavian artery
- typically noted in area where ductus arteriosus attaches
- NB may be asymptomatic if mild case of PDA (patent ductus arteriosus)
- severe cases will have HF or shock w/ PDA closes
- up to 30% of infants w/ this have Turner’s syndrome
- Female infants noted to have coarctation should get a karyotype analysis - compare femoral and brachial pulses simultaneously
- absence or delay of femoral pulse when it compared w/ brachial pulse is diagnostic
- compare femoral and brachial pulses simultaneously
S/Sx
- neonate is pale, irritable, dyspneic, and diaphoretic
Labs:
- If abnormal, order cardiac echocardiogram, EKG, and CXR
- May be asympatomatic
- Take BP of both arms and thighs
Normal: SBP higher in legs than in arms
Abnormal: SBP higher in arms than thighs → palpate pulse in all 4 extremities; there is a delay or change in amplitude of pulses
- bounding radial pulses are compared w/ femoral pulses
Developmental Dysplasia of the Hip
1. Definition/Etiolgy
2. Screening: Birth-3 months
3. Maneuver/Tests
4. Abnormal; next steps
5. Older infants (≥4 months)
Developmental Dysplasia of the Hip (DDH)
1. Definition/Etiolgy
2. Screening: Birth-3 months
3. Maneuver/Tests
4. Abnormal; next steps
5. Older infants (≥4 months)
- RF:
- breech births
- female
- family hx
- oligohydramnios - look of asymmetry in creases of legs
- examine infant front and back w/out diapers
- check that gluteal, thigh, and popliteal folds match
* if asymmetry of thigh/gluteal folds → R/O congenital hip dysplasia or hip fracture
- look of asymmetry in creases of legs
- Barlow Maneuver/Test
- Ortolani Maneuver/Test
* Avoid performing both tests to many times pe visit, because hip ligaments can become damaged
- Barlow Maneuver/Test
- If either screening exam is positive, refer to pediatric orthopedist
- Order US of hips
- If either screening exam is positive, refer to pediatric orthopedist
- Continue to perform Barlow and Ortolani maneuvers until child is fully weight bearing/walking
- Look for leg that is turned outward
- One femur appears shorter when infant is supine (Galeazzi sign)
- hip has limited range of motion
Abnormal: If preceding findings are present, order hip US and refer to orthopedic specialist
- Continue to perform Barlow and Ortolani maneuvers until child is fully weight bearing/walking
Galeazzi sign
One femur appears shorter than infant is supine (in Dysplasia of the hip)
Barlow Maneuver/Test (DDH)
- Place index and middle finger over greater trochanter
- Gently push both knees together at midline downward, then pull upward
- will hear “clunk” sound when trochanter slips back into acetabulum (reducible dislocated hip)
POSITIVE: “Clunk” sound or palpating trochanter being displaced by index/middle finger → Positive testing indicates that the femoral head is partially or completely dislocated from the acetabulum
Ortolani Maneuver/Test (DDH)
- Hold each knee and place middle finger over greater trochanter (outer thigh over hips)
- rotate hips in frog leg position (abduction, then adduction)
- during abduction, resistance may be felt at 30-40º
POSITIVE: “click” or “clunk” sound and/r if examiner palpates trochanter being displaced (temporarily) from hip socket → Positive testing indicates that the femoral head is partially or completely dislocated from the acetabulum
