The Pediatric Visit and the Newborn Flashcards
Neonate/Newborn
First 28 days of life
Infant
29 days - 1 year
Early childhood
1-4 years old
Middle childhood
5-10 years old
Adolescence
10-20 years old
Early adolescence
10-14 years old
Middle adolescence
15-16 year old
Late adolescence
17-20 years old
Pediatrics technically go to age ______
21
Predictable development
age specific milestones
A ___________ or a milestone is always concerning
Loss/delay
Children mature at ________ rates
different
Development is impacted by
physical, social and environmental factors
H&P ________ depending on the developmental stage of the child
varies
Pediatric health supervision visits are also known as
well child check (WCC)
Goals of pediatric visit
disease of detection
disease preventions
health promotion
anticipatory guidance
Components of pediatric visits
interval history
surveillance of development
review of symptoms
observation of parent/child interaction
physical exam screening, including measurement of growth
screening (universal and risk assessment)
immunizations
anticipatory guidelines
Surveillance vs. screening
surveillance is ongoing
developmental screening is a formal process
Developmental surveillance
ongoing process
done at every visit
parental history
skilled, experienced observation
Developmental screening
formal process
uses a standardized tool
universal screening at specified ages
selective screening when risk assessment raises a concern
HPI for an acute pediatric problem
content is very similar to an adult- determine what is age appropriate
Differences in pediatric vs. adult
getting a history from a parent
Need to get both child’s parents perspectives (especially as child ages)
Note parent-child interaction
Parental emotions and behaviors
HPI for well child visit
Any parental concerns and child concerns as they age
Since last visit:
any changes
general status
other priorities depend on the age of the child
Past medical history pediatric visit
includes medical illnesses, surgeries, hospitalizations, psychiatric, OB-GYN)
Additional past medical history for pediatric visit different from adult
prenatal history of the mother
birth history
newborn history (included for all children age 3 and under, included for other children if pertinent, often listed first under PMH)
Prenatal history
mother’s age at history
previous pregnancy history (which number of pregnancy, any difficulty getting pregnant, miscarriages/abortions)
Maternal illnesses during pregnancy
Medication exposure during pregnancy
Complications of pregnancy
Newborns: mother’s blood type, infectious disease screening
Birth history (Perinatal)
duration of pregnancy
kind and duration of labor
Type of delivery
use of medications during delivery
conditions of the child at birth
need for resuscitation at birth
APGAR scores
complications of delivery
APGAR
A: activity
P: pulse
G: Grimace (reflex irritability)
A: Appearance (skin color)
R: Respirations
Newborn history
Birth weight, length and head circumference
Complications after birth (jaundice, respiratory problems, seizure, bleeding, cyanosis, feeding problems, excessive weight loss, cardiac concerns)
Did the baby go home with the mother
28yo G2P2002 )+ mother
Mother received prenatal care in the first trimester
prenatal labs were GBS-, HIV-, GV-, chlamydia-, RPR (syphilis) reactive
Mom reports no medications taken during pregnancy or delivery
Example Prenatal history
Full term
Normal spontaneous vaginal delivery (NSVD)
Delivery was uncomplicated, no resuscitation was required
APGARS: 8 at 1 min, 9 at 5 min
Example Birth history
3445 grams, HC 35 cm, length 50cm
Nursery course was uncomplicated
Infant went home with mom on day of life (DOL #2)
Example Newborn history
health maintenance pediatric note
Feeding/nutrition
Growth and development
immunizations
sleep patterns
elimination patterns
dental care
safety
Feeding history/nutrition pediatric note
breast vs bottle fed (how much, how frequent)
weaning
Solid foods (when what type)
Current diet
Food likes/dislikes, appetite, intolerances
Vitamin supplements
Growth and development pediatric note
summarize growth history
developmental milestone history (fine motor, gross motor, language-expressive and receptive, social)
Older children: pubertal development, school issues, keeping up compared to peers and siblings
Immunization history pediatric note
Need the actual dates and types of vaccines documented
include reactions/complications
must be specific- DO NOT WRITE UP TO DATE
Other health maintenance pediatric note
sleep patterns, elimination patterns, dental care, safety issues
Family history pediatric note
age of parents, siblings, grandparents and their health
Focus common pediatric diseases: asthma, ADHD, febrile seizures, diseases with genetic components
Pediatric focused history interview
needs to be age and problem specific
Include family history pertinent to the chief complaint
Social history pediatric note
age dependent
Living situation: who is in the home, what are the relationships, marital status of the parents/involvement
Childcare: who, where, ages
Activities/hobbies
School: how is it going, relationships with peers and teachers
Stressors at home: financial, relationships, deaths
Pets
Exposure: tobacco
Safety: Firearms (locked, secured, ammo), Water source (well vs city), Smoke and CO detectors, sun protection
HEADSS
Home: living arrangements
Education and Employment: school, future plans
Activities: hobbies, exercise, risk-taking
Drug use: cigarettes, alcohol, drugs, caffeine
Sexual activity and sexuality: onset, safe sex,
Suicide: depression, mental health
Pediatric ROS note
follows same structure, age appropriate
weight changes, patterns of growth
unusual head shape, strabismus, visual complaints
dental issues
wheezing
heart murmurs, exercise tolerance
scoliosis
puberty
fussy, clingy
Prenatal visit note
recommended early in 3rd trimester to help build a relationship with the provider, answer parental concerns, identify potential issues
Provide education: newborn screening, community resources, circumcision, breast feeding, car seats, sleeping on back, pets, water temperature for baths/feeding
Initial evaluation of the newborn: Immediate
drying, clearing airway, warming
Initial evaluation of the newborn: key questions
full term?
Good muscle tone?
Is the intent breathing or crying?
If yes to all 3, likely no need for resuscitation and keep the baby with mom
APGAR score
scoring system to assess the need for resuscitation and the response to the resuscitation (if needed)
when is APGAR scoring performed
Done at 1 minute and 5 minutes in all newborns
Scoring for APGAR goes from ________
0 to 10
APGAR score: 0-4
Severe depression, requiring immediate resuscitation
APGAR score: 5-7
some nervous system depression
APGAR score: 8-10
normal
APGAR score post 5-minutes
0-3: low (likely NICU)
4-6: moderately abnormal (needs close attention)
7-10: reassuring
APGAR scores does not predict ________ or __________ outcome
individual mortality, neurologic outcome
APGAR scores during resuscitation are NOT the equivalent of an APGAR in a baby with __________
spontaneous repirations
Newborn assessment
should happen during the first day of life.
A comprehensive exam.
Parents present and 1-2 hours after a feeding
Newborn history
review of pregnancy, labor and delivery (including screening tests and risk factors for sepsis)
Review of past pregnancies (congenital abnormalities, still birth)
Review mother and father medical and genetic history
Newborn physical exam
Look before touching
At rest, moving all extremities, turns to a parent’s voice, inspect facies, pink, good tone, respiratory effort, obvious deformities
Order for Newborn physical assessment
Inspect
HEART LUNGS (require a quiet baby)
then spine/hip assessment/agitation last
Newborn vitals Temp, RR, HR
Temp: 36.5-37.5 (97.7-99.5)
RR: 35-60 (count for a full minute)
HR: 120-160 (can be as low as 80-90 during sleep)
Newborn head circumference
done at every visit until age 2
Should you see jaundice in a newborn or in the first day of life?
skin should NOT be jaundiced at birth or within the first day of life
When does physiologic jaundice start?
Day 2-3 of life
Lanugo
Fine downy growth of hair over the entire body, more common in preemies, shed in the first few weeks of life
Vernix Caseosa
cheesy casing present at birth
Normal cyanosis findings in a newborn
Acrocyanosis
palms and soles
perioral
ABNORMAL cyanosis findings in a newborn
mucous membranes, central/trunk
If central or mucous membrane cyanosis is present this indicates _________
possible congenital heart disease
How long does acrocyanosis last
first 24-48 hours of life
what is Milia
AKA newborn acne
pinhead white raised areas due to retention of sebum in the openings of sebaceous glands.
When does milia appear?
Can be present at birth or appear in the first few weeks of life.
Milia treatment?
Nothing. Gradually disappear.
What is Pustular melanosis
small, vesicolopustular lesions with a brown macular base.
What population presents with pustular melanosis
Black babies
How long does pustular melanosis last
several months
What is erythema toxicum
erythematous macula’s with central pinpoint vesicles that cover the body.
When does erythema toxicum appear
appear on day 2-3
How do you treat erythema toxicum
disappear in a week or so
what are other names for Nevus simplex
AKA salmon patch or stork bite
What is congenital dermal melanocytosis
AKA mongolian spot
blue-gray patch usually in the sacral-gluteal region or shoulders
What population is most common in congenital dermal melanocytosis
Asian (85-100)
Black (60%)
Hispanic (45-75)
Less than 10% white
How long does it take for a congenital dermal melanocytosis to resolve
fade during first 1-2 years of life but can stay until age 10 (really age 8 seen in Waldron’s practice)
What is another name for a port wine stain
nevus flammeus
What is a nevus flammeus
AKA port wine stain
Capillary malformation in the skin, usually an isolated patch that grows in proportion to the child’s growth
What conditions are related to nevus flammeus
If in V1/2 of CN5
Sturge-Weber syndorme (rare, congenital)
Capillary-venous malformations in the brain and eye
Neonatal head inspection
Inspect for symmetry
Neonatal head palpation
Anterior fontanelle (closes between 4-26 months)
Posterior fontanelle (closes by 2 months of age)
Neonatal facial exam
look for symmetry, palsies, abnormal feature
Features associated with Down syndrome on facial exam
epicanthal folds
slanted palpebral fissures
flat nasal bridge
protruding tongue
Neonatal eye exam
Eyelids often edematous at birth
symmetry
Spacing
pupils
red reflex
eye movements
Normal ear measurement
line drawn across acanthi of the eye to the occipital protuberance should cross 1/3 down the pinna or auricle
Ear abnormalities can be associated with
congenital kidney defects or congenital hearing loss, turner syndrome, Down syndrome, trisomy 18
Can you do an eye exam on a newborn with an otoscope?
No, vernix cases obstructs the tympanic membrane for several days
How do neonates breathe
most infants are obligate nose breathers
Neontal nose exam
assess patency of nasal passages
Do you suck out the mouth or the nose first after a birth
mouth
Neonatal mouth and pharynx exam
palpate gums, assess for cleft lip and palate, inspect tongue and frenulum
Natal teeth
early eruptions of normal teeth but can be part of congenital syndromes
Epstein pearls
white cystic vesicles on median palate, resolve spontaneously
Ankyloglossia
tongue tie
What does ankyloglossia cause
potential breast feeding/latching issues, potential speech issues later in life
Neonatal neck and clavicle exam
inspect for masses, branchial cleft cysts and clavicle fractures
What does a webbed neck indicate
Turner’s syndrome
Where are branchial cleft cysts located
dimples or openings located anterior to the SCM
If crepitus is found on the clavicle in the neonate it can indicate
clavicle fracture
Neonatal chest and lung exam
inspect for symmetry, breasts, respirations, auscultation
Breast enlargement on neonates is due to ________ and can produce ___________
maternal estrogen, witches milk
Widely spaced nipples can be a sign of
Turner syndrome
Abnormal respirations in a neonate would be
retractions, grunting, nasal flaring
Compared to adults what are infant breath sounds like
louder and harsher than adults
Is percussion helpful in neonates
no
Neonatal heart exam
inspect for cyanosis, palpate for peripheral pulses (femoral, brachial), thrills
Where is PMI located on a baby
4th intercostal space
Auscultation of neonate exam
S1, S2 (split is normal but you probably won’t be able to hear it)
Is S3 in a neonate a red flag?
no. is frequently heard and normal
Murmurs can be ________ vs __________
functional vs. pathologic
Neontal abdominal exam
inspect, auscultate, palpate
When is the umbilical cord remnant usually gone by
2 weeks
Umbilical anatomy has
2 arteries, 1 umbilical vein
What is a single artery in the umbilical cord associated with
abnormalities in 20% of cases
Where is the liver edge felt on an abdominal exam of a neonate?
1-2cm below costal margin
Can you feel a spleen in a neonate
yes, palpable spleen tip is normal
When would you do a rectal exam on a neonate
if they have not pooped to check for imperforate anus, possible hirshprungs disease
Neontal genital exam
done to identify gender
Female neonatal genital exam
genitalia prominent d/t maternal estrogen, can have discharge from nipples
Male neonatal genital exam
foreskin not retractible at birth, check for hypospadias, possible scrotal edema d/t maternal estrogen, determine location of testes (scrotum vs. abdomen)
Neonatal MSK exam
count fingers and toes, look for deformities, inspect spine
What is a normal finding in a newborn concerning their lower extremities
bowlegged
What are pigmented spots, hairy patches, deep pits possibly associated with
neural tube defects
Neonatal hip assessment should be performed for how long
Barlow and Ortolani maneuver done at newborn assessment through 3 months
How do you do the Barlow maneuver
attempting to dislocate hip
knees and hips are flexed, adduct (in) while pushing posteriorly
Positive: clunk on dislocation
internal rotation
How do you do the Ortolani maneuver
relocating the hip
legs at right angles, index over GT and thumbs over lesser trochanters, abduct both hips
Positive: clunk on relocation
external rotation
How do you do the Ortolani maneuver
relocating the hip
legs at right angles, index over GT and thumbs over lesser trochanters, abduct both hips
Positive: clunk on relocation
external rotation
Neonatal neuro exam
note muscle tone, symmetry of movement, moving all extremities, primitive reflexes
Moro reflex
AKA startle reflex
sudden, slight dropping of head from slightly raised supine position. Open hands and extension/abduction of arms ant hen flextion and crying.
When does the Moro reflex disappear
5-6 months
When does the palmar grasp reflex disappear
5-6 months
when does the plantar grasp reflex disappear
9-10 months
When does the stepping reflex disappear
1-2 months
When does the rooting reflex disappear
2-3 months
When does the Babinski disappear
9-24 months
Asymmetrical tonic neck reflex
AKA fencer’s position
Neonatal preventative care: Eyes
Erythromycin ophthalmic ointment or silver nitrate to prevent gonococcal conjunctivitis
Neonatal preventative care: heme
Vitamin K injection to prevent vitamin K deficient bleeding (VKDB) 1mg IM
Neonatal preventative care: Hepatitis
Hepatitis B vaccination. If mom is + baby also get IVIG
Universal Newborn Screening: pulmonary
pulse oximetry
Universal newborn screening: ears
Hearing (otoacoustic emissions, automatic auditory brainstem response)
Universal newborn screening: metabolic and genetic disorders
Cystic fibrosis, PKU (phenylketonuria)
Universal newborn screening: endocrine disorders
congenital hypothyroidism, congenital adrenal hyperplasia
Universal newborn screening: heme
sickle cell anemia
