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ANCC - Fitzgerald Notecards > Pediatrics: Newborns and Infants > Flashcards

Pediatrics: Newborns and Infants Flashcards

1
Q

Danger Signals: Failure to Thrive

A

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

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2
Q

Danger Signals: Down Syndrome

A
  • 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

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3
Q

Danger Signals: Fetal Alcohol Syndrome

A
  • 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
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4
Q

Danger Signals: Cryptorchidism

A

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
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5
Q

Danger Signals: Gonococcal Ophthalmia Neonatorum

A
  • 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

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6
Q

Danger Signals: Chlamydial Ophthalmia Neonatorum (Trachoma)

A
  • 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

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7
Q

Danger Signals: Chlamydial Pneumonia

A
  • 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

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8
Q

Danger Signals: Sudden Infant Death Syndrome

A
  • 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

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9
Q

Danger Signals: Excessive Weight Loss (>10%)

A
  • 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

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10
Q

Danger Signals: Dehydration

A
  • 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
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11
Q

Skin lesions: Congenital Dermal Melanocytosis

A

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
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12
Q

Skin lesions: Milia

A

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

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13
Q

Skin lesions: Erythema Toxcum Neonatorum

A
  • 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
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14
Q

Skin lesions: Seborrheic Dermatitis

A

“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

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15
Q

Skin lesions: Faun Tail Nevus

A
  • 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
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16
Q

Skin lesions: Cafe Au Lait Spots

A
  • 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
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17
Q

Skin lesions: Vascular Leions - Salmon Patches

A

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

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18
Q

Skin lesions: Vascular Lesions - Port Wine Stain

A

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

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19
Q

Skin lesions: Vascular Lesions - Hemangioma

A

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

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20
Q

Vision Screening: NB Vision

A
  • 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
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21
Q

Vision Screening: Infant Screening
1. 1 month
2. 3 months
3. 6 months
4. 12 months
5. Retina and optic disc

A
  1. infant can fixate briefly on mother’s face; prefers human face
  2. 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
  3. Makes good eye contact
    - turns head to scan surroundings w/ 180º visual field
  4. 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
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22
Q

Vision - Abnormal Findings: Strabismus

A
  • 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

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23
Q

Esotropia

A

inward turning of the eyes

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24
Q

Exotropia

A

Outward turning of the eyes

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25
Q

Hypertropia

A

one one higher than the other

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26
Q

Hypotropia

A

one eye lower than the other

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27
Q

Diplopia

A

double vision

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28
Q

Vision - Abnormal Findings: Amblyopia

A

“Lazy eye”
- If corrected early, affected eye can have normal vision

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29
Q

Vision - Abnormal Findings: Esotropia

A
  • 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
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30
Q

Vision - Abnormal Findings: Indications for Referral

A
  • 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)
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31
Q

Vision - Abnormal Findings: Red Reflex

A
  • 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

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32
Q

Vision - Abnormal Findings: Congenital Cataracts

A
  • Red reflex exam on neonate shows a round, white-colored pupil
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33
Q

Vision - Abnormal Findings: Hirschberg Test

A

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

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34
Q

Hearing Screening: Universal screening

A

Universal screening for hearing loss is done while in nursery before discharge

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35
Q

Hearing Screening: Newborns

A
  • Each state has its own rules about neonatal hearing exams
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36
Q

Hearing Screening: Auditory Brainstem Response

A
  • ;Measures CN VIII by use of “click” stimuli
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37
Q

Hearing Screening: Otoacoustic Emissions
1. Gross hearing test

A
  1. 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)
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38
Q

Hearing Screening: Mnemonic Device (HEARS) for High-risk factors for Hearing loss

A

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

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39
Q

Infant Lab Tests: Lab drawing techniques

A
  • 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
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40
Q

Infant Lab Tests: Thyroid-Stimulating Hormone

A
  • federally mandated
  • Lack of thyroid hormone results in mental and somatic growth retardation
  • treated by thyroid hormone supplmentation
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41
Q

Infant Lab Tests: Phenylketonuria

A
  • 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)

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42
Q

Infant Lab Tests: Sickle Cell Disease

A
  • Required test can detect 4 types of hemoglobin: F, S, A, and C
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43
Q

Infant Lab Tests: Hemoglobin and Hematocrit

A
  • 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
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44
Q

Infant Lab Tests: Lead Screening

A
  • 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)
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45
Q

Nutritional Intake: what is preferred for babies?

A

Breastfeeding is preferred over formula
- If formula chosen, start w/ one fortified w/ iron

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46
Q

Breastfeeding
1. Give what vitamin w/breastfeeding?
2. How many calories per ounce?
3. Why breastfeeding?

A
  1. 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
  2. Breast milk or formula contains 20 calories/ounce
  3. ↓ risk of infections (e.g., otitis media) during the first few weeks of life
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47
Q

Breastfeeding: Colostrum

A
  • 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)
48
Q

Nutritional Intake: Cow’s Milk

A
  • Avoid cow’s milk the first year of life (causes GI bleeding)
  • Common cause of iron-deficiency anemia in babies and young children
49
Q

Nutritional Intake: Solid Foods

A
  • 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)
50
Q

Elimination: Meconium

A
  • 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
51
Q

Head Findings: Caput succedaneum

A
  • 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)

52
Q

Head Findings: Head Circumference

A

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)
53
Q

Abnormal Head Finding: Cephalohematoma

A
  • Traumatic subperiosteal hemorrhage
  • R/O skull fracture

→ Order radiographs of skull
- swelling does NOT cross the midline or suture lines

54
Q

Weight Gain and Length: Birth Weight

A
  • 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
55
Q

Weight Gain and Length: Infant Weight
1. 0-6 months
2. 6-12 months

A
  1. 6-8 ounces/week and 1 inch per month
  2. 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

56
Q

Length and Height

A

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

57
Q

Dentition: First Teeth
1. S/Sx
2. 6-10 months
3. 2.5 yo

A

Primary teeth
Both left and right teeth erupt bilaterally at the same time (symmetrical)

  1. symptoms are drooling, chewing on objects, irritability, crying, and low-grade fever
  2. lower central incisors (lower front teeth)
  3. Has complete set of primary teeth (20 teeth)
  • Will typically lose teeth in same order that they erupt
58
Q

Dentition: First Permanent Teeth

A

Deciduous Teeth
@ 6 years of age
- shed central incisors
- first permanent teeth to erupt are upper and lower first molars

59
Q

Genitourinary Anomalies: Hypospadias

A

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
60
Q

Genitourinary Anomalies: Epispadias

A

Urethral meatus is located on dorsal aspect (upper side) of penis

  • Urethral opening on top of glans/shaft → Refer to pediatric urologist
61
Q

Genitourinary Anomalies: Hydrocele

A

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)
62
Q

Genitourinary Anomalies: Genitourinary Anomalies: Newborn Female vagina swollen w/ small amount of blood-tinged discharge

A

Caused by withdrawal of maternal hormones
- disappears within a few days

63
Q

Genitourinary Anomalies: Cryptorchidism

A
  • 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

64
Q

Epstein’s pearls

A

White papules found on gum line resembling an erupting tooth

65
Q

Reflex Testing: Anal Wink

A

Gently stroke anal region
- Look for contraction of perianal muscle
* Absence is abnormal → suggestive of lesion on spinal cord (e.g., spina bifida)

66
Q

Reflex Testing: Plantar Reflex

A

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

67
Q

Reflex Testing: Palmar Reflex

A

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

68
Q

Reflex Testing: Moro Reflex

A

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
69
Q

Reflex Testing: Step Reflex

A
  • 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

70
Q

Reflex Testing: Blink Reflex

A
  • Eyelids will close in response to bright light or touch
71
Q

Reflex Testing: Tonic Neck Reflex

A

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

72
Q

Reflex Testing: Rooting Reflex

A

Stroke corner of mouth causes baby to turn toward stimulus and suck
- disappears by 3-4 months

73
Q

Mumps, Measles, and Rubella (MMR) and Varicella Vaccine

A
  • 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

74
Q

Influenza vaccine

A
  • 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)
75
Q

Influenza vaccine Contraindications

A
  • 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)
76
Q

Live Influenza Nasal Spray (FluMist)

A
  • 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
77
Q

Diphtheria, Tetanus, Pertussis Vaccines (DTaP)

A
  • 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)
78
Q

Side Effects: DTaP/DT
+ Contraindications
+ Precautions
+ Not considered contraindications

A
  • 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

79
Q

Vaccine Adverse Event Reporting System

A
  • national postmarking vaccine safety surveillance program in US managed by both CDC and FDA
  • report vaccine adverse events
80
Q

Immunization Tips:

A

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)

81
Q

Which vaccine is only given at birth?

A

Hepatitis B

  • If Hep B surface antigen (HBsAg)-positive mother, give neonate hepatitis B immunoglobulin (HBIG) and Hep B vaccine
82
Q

If ≥7 years, which vaccine to use? DTaP or Tdap?

When to give Tdap as booster?

A

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)

83
Q

When should you give MMR and varicella?

A

Do NOT give before 12 months.

84
Q

What is the youngest age for influenza vaccine?

A

6 months

85
Q

Exam Tip: What may not appear on exam regarding vaccine timelines?

A

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)
86
Q

Growth and Development: Newborns

A
  • 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
87
Q

Growth and Development: 2 months

A
  • follows objects past midline
  • Coos vowels (e.g., “aa”) and makes gurgling sounds
  • lifts head 45º when prone
  • Smiles in response to another
88
Q

Growth and Development: 4 months + Fine/Gross Motor Skills

A
  • 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)

89
Q

Growth and Development: 6 months + Fine/Gross Motor Skills + language

what to report?

A

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

90
Q

Growth and Development: 9 months + Fine/Gross Motor Skills + Language

A

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)

91
Q

Growth and Development: 12 months + Fine/Gross Motor Skills + Language

A

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

92
Q

Growth and Development: 15 months + Fine/Gross Motor Skills + Language

A

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

93
Q

Growth and Development: 18 months + Fine/Gross Motor Skills + Language

A

Fine Motor:
- Turns pages of book

Gross Motor:
- Can walk up steps

Language:
- Can point to 4 body parts
- Vocab of 10-20 words

94
Q

Safety Education

A
  • 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
95
Q

Choking prevention

A
  • 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
96
Q

Car Safety

A
  • 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)
97
Q

Car Safety Seats: Infants and toddlers

A

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

98
Q

Car Safety Seats: Toddler-Preschool

A

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

99
Q

Car Safety Seats: School age

A

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

100
Q

Car Safety Seats: Older child - teenager

A

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

101
Q

Toxic Exposures

A

chronic exposure to second-hand smoke ↑ risks for:
- SIDS
- otitis media
- bronchitis
- pneumonia
- wheezing
- coughing

  • Also affects lung development and exacerbates asthma
102
Q

Jaundice (hyperbilirubinemia)
1. Definition/Etiology/Pathology

A
  • 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

103
Q

Jaundice (hyperbilirubinemia): Physiologic Jaundice

A

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)
104
Q

Jaundice (hyperbilirubinemia): Breast Milk Jaundice

A
  • 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
105
Q

Jaundice (hyperbilirubinemia): Breastfeeding Jaundice

A
  • 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)
106
Q

Jaundice (hyperbilirubinemia)
2. Treatment Plan

A
    • 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)

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

107
Q

Jaundice (hyperbilirubinemia)
3. Complications

A
  1. 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
108
Q

Physiologic Anemia of Infancy

A
  • 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
109
Q

Congenital Lacrimal Duct Obstruction (Dacryostenosis)
1. Definition/Etiology
2. Clinical Presentation
3. Treatment
4. Complication(s)

A
    • AKA congenital nasolacrimal duct obstruction
      - occurs in approx 6% of newborns
      - usually resolves spontaneously w/in 6 months in majority of infants (90%)
  2. 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
  2. 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
110
Q

infant Colic (Rule of 3s)

A
  • 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

111
Q

Coarctation of the Aorta
1. Definition/Etiology
2. Screening/S&Sx/Labs
3. Older Infants (Normal vs abnormal)

A
  1. 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

S/Sx
- neonate is pale, irritable, dyspneic, and diaphoretic

Labs:
- If abnormal, order cardiac echocardiogram, EKG, and CXR

  1. 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
112
Q

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)

A
113
Q

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)

A
  1. 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
    • Barlow Maneuver/Test
      - Ortolani Maneuver/Test
      * Avoid performing both tests to many times pe visit, because hip ligaments can become damaged
    • If either screening exam is positive, refer to pediatric orthopedist
      - Order US of hips
    • 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
114
Q

Galeazzi sign

A

One femur appears shorter than infant is supine (in Dysplasia of the hip)

115
Q

Barlow Maneuver/Test (DDH)

A
  • 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

116
Q

Ortolani Maneuver/Test (DDH)

A
  • 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

ANCC - Fitzgerald Notecards (27 decks)

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