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What may be the cause of an symptomatic abdominal mass at a 9 mo visit?



Assessment of Development at a Well-Child Visit:

1. May be assessed using one of several developmental screening tests (eg, the Parents' Evaluation of Developmental Status (PEDS), Ages and Stage, or the Denver II Developmental Screening Test).
2. The American Academy of Pediatrics (AAP) mandates developmental screening at 9 mo, 18 mo, and 30 mo checkups.
3. Specific autism screening is recommended at 18 mo and age 2 yr
4. Many offices do developmental screening at every health maintenance visit, especially if the office takes care of children that have been medically underserved.
5. Tests may involve parental reports and/or examination in the office.


Breast milk:

Preferred source of nutrition for most babies.



Commercial formulas provide complete nutrition for those babies whose mothers are unable or unwilling to breastfeed. Available formulas include those made with:
1. Cows milk protein
2. Soy protein
3. Hydrolyzed cows milk protein
There are also specialized formulas that provide protein in the form of simple amino acids (the true elemental formulas)


Preparing formula:

1. Ready to feed formula: Baby is fed directly from the bottle
2. Powder: 2 scoops of the powder are mixed with 4 oz water
3. Formula concentrate: ratio is 1 part concentrate to 1 part water
There is no need to give an infant extra bottles containing water only, because formula or breast milk fulfills maintenance fluid requirements.


Transition to Regular Cow's Milk:

It is important never to give regular cow's milk until 12 mo of age. Infants do not tolerate the protein mixture of unaltered cows milk and may develop colitis, causing microscopic bleeding and gradually worsening anemia.


When are babies expected regain their birth weight?

As early as 1 week of age, but definitely by 2 weeks of age.


What is the caloric requirement of most healthy term babies in the first 1 to 2 months of life?

100 cal/kg/day


Adequate growth for a term infant:

Requires approximately 100 to 120 cal/kg/day. The average daily wt. gain for a term infant is 20 to 30 grams.


What calorie intake do preterm infants require?

115 to 130 cal/kg/day


What calorie intake do VLBW (very low birth weight) infants require?

Up to 150 cal/kg/day.


When does the moro reflex disappear?

4 months


What can the moro reflex be used to detect?

Peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries.


What is the PEDS screening tool?

A developmental screening test used by pediatricians. This tool is (1) Evidence-based (2) Used for children between 0 and 8 years of age (3) Able to be performed at all well-child visits (4) Used to identify those children who may have developmental delay and who may need a more formal evaluation. Parents are asked to answer ten Qs on the PEDS response form. The questions elicit parents' perspectives on their child for each developmental domain.


What developmental milestones should a 2 mo old infant reach?

1. Gross motor - head up 45deg (50-90percent), lift head (90percent)
2. Fine motor - follow past midline (50-90percent), follow to midline (90percent)
3. Cognitive, linguistic, and communication - laugh (50-90percent), vocalize (90percent)
4. Social-Emotional - smile spontaneously (50-90percent), smile responsively (90percent)


What developmental milestones should a 4 mo old infant reach?

1. Gross motor - Roll over (50-90percent), Sit - head steady (90percent)
2. Fine motor - follow to 180deg (50-90percent), grasp rattle (90percent)
3. Cognitive, linguistic, and communication - turn to rattling sound (50-90percent), laugh (90percent)
4. Social-Emotional - regard own hand (90percent)


What developmental milestones should a 6 mo old infant reach?

1. Gross motor - Sit - no support (50-90percent), roll over (90percent)
2. Fine motor - look for dropped yarn (50-90percent), reach (90percent)
3. Cognitive, linguistic, and communication - turn to voice (50-90percent), turn to rattling sound (90percent)
4. Social-Emotional - feed self (50-90percent), work for toy (out of reach) (90percent)


What developmental milestones should a 9 mo old infant reach?

1. Gross motor - Pull to stand (50-90percent), Stand holding on (90percent)
2. Fine motor - take 2 cubes (50-90percent), pass cube (transfer) (90percent)
3. Cognitive, linguistic, and communication - dada/mama, nonspecific (50-90percent), single syllables (90percent)
4. Social-Emotional - wave bye-bye (50-90percent), feed self (90percent)


When can some infants be started on rice cereal with a spoon?

Age 4 months


What is the recommended daily allowance of vitamin D?

400 units per day


What is a nutritional concern with children who are exclusively breast fed?

1. While there is evidence that breast milk is superior, there has been a concern that the amount of vitamin D in breast milk is not adequate. Unless an infant or child is drinking 32 ox of formula or milk a day (both of which are supplemented with vitaD already), they may not receive enough vitamin D.
2. Infants and children who are exclusively or mostly breastfed therefore should be supplemented, as should infants and children drinking less than a quart per day of formula or cows milk.
3. The easiest/most cost effective way to supplement is a multivitamin. Infants can use liquid vitamin drops; older children can take chewable multivitamins.


When do babies start sleeping through the night?

Usually by age 4-6 months. To help prevent SIDS, an infant should continue to be placed on her back to go to sleep.


What car seat position is most appropriate at 2 mo of age?

Middle back seat, facing rear.


Car Seat Safety Tips

Children under age 13 yo should not sit in the front seat. Car seats for children are required in all 50 states. The most effective car-seat restraint is a five-point harness, consisting of two shoulder straps, a lap belt and a crotch strap.


What vaccinations are given at the 2 mo visit?

First doses of DTaP, Hib, IPV, PCV13, RotaV and second dose of HepB.


When are the MMR and HepA vaccines given?

12 mo of age


Over the first 5 yr, every child should receive the following numbers of doses of each type of vaccine:

1. DTaP (5)
2. IPV (4)
3. Hib (3 or 4, depending on the vaccine manufacturer)
4. PCV13 (4)
5. MMR (2)
6. Varicella (2)
7. RotaV (2 or 3, depending on the vaccine manufacturer)
8. HepA (2)
9. HepB (3)


Seasonal influenza vaccine:

Annual vaccination strongly recommended for all children 6 through 59 mo of age. Also strongly recommended or household contacts and caregivers of children 0 to 59 months and children and adolescents in high risk groups (asthma, lung, heart, immune system problems). Vaccine routinely recommended for all children under age 19 years.


What are some combination vaccines?

Pediarix (combines DTaP, HepB and IPV), Pentacle (combines DTaP, IPV and Hib)


What are common side effects of vaccines?

"Knots" in the skin at the injection site (which may persist for a few weeks) or fussiness and fever for 24 hours.


By what ages should an infant double or triple his or her birthweight?

Double by 4-5 mo, triple by 12 mo.


When will most children reach double their birth length?

By age 4 years.


What is the Red Reflex?

Red or orange color reflected from the fundus through the pupil when viewed through an ophthalmoscope approximately 10 inches from the patient.


How do you interpret the red reflex?

Caucasian - usually bright red
Other ethnic groups - color may be variable but will be darker
Look for symmetric coloration and no leukocoria (white spots)


What abnormalities are indicated by an absent red reflex?

Cataracts, Glaucoma, Retinoblastoma and Chorioretinitis


What are the 6 mo gross motor milestones?

Rolls over, sits unsupported and no head lag when pulled to sit from supine


What are the 6 mo fine motor milestones?

Reaches for objects and looks for dropped items


What are the 6 mo language milestones?

Turns toward voice, babbles (use of repetitive consonants ba ba ba, da da da)


What are the 6 mo social and adaptive milestones?

Feeds self, demonstrates stranger recognition - prelude to stranger anxiety


What are some steps parents and guardians should take to childproof their home?

Installing outlet covers, putting in cabinet locks, setting up stair barriers, making sure learning supplies and medicines are safely stored. Keep the number for poison control close to the phone.


What anticipatory guidance other than home safety should be discussed with Asia's parents?

Car seat placement, use of a walker, dietary changes, expected developmental changes and sleep patterns


Where should the car seat be at 6 mo of age?

In the back seat, facing the rear


What has the AAP recommended about the use of walkers?

AAP has recommended against the use of walkers because of the risk of injury, especially when there are stairs in the home. In addition, walkers do not teach children to walk any earlier than they otherwise would.


What dietary changes can be made at 6 mo of age?

New foods may be added to Asia's diet every 5-7 days.


What developmental changes can be expected at 6 mo of age?

Children may be resistant to being away from their mothers - this "stranger anxiety" is normal. This is a great time to start reading to kids. Kids this age should be expected to take two naps per day and will probably sleep through the night.


Acetaminophen and Vaccines:

Acetaminophen use may cause a lower antibody response for some immunizations and it should be administered only if absolutely necessary.


What are two developmental milestones you'd expect to see in a 9 mo old infant?

Wave bye-bye and sits without support.


What are the 12 mo developmental milestones?

Gross motor - stands alone, may can walk well
Fine motor - has well developed, "neat" pincer grasp
Language - says mama and dada and 1 or 2 other words
Social/adaptive - hands parent a book to read, points when wants something, imitates activities and plays ball with examiner


When should a rectal exam be done in an infant?

The rectal exam is not a routine part of the infant physical exam. It should be done when an intra-abdominal, pelvic or perirectal process is suspected.


How do you perform a rectal exam in an infant?

(1) Lay the infant supine (2) With one hand, hold the feet and flex the knees and hips on the abdomen (3) Insert your gloved and lubricated finger of your other hand into the rectum (4) Palpate for hard stool and/or mass


What should be on your differential diagnosis if you notice an intraabdominal mass?

Hepatic neoplasm, Hydronephrosis, Neuroblastoma, Teratoma, Wilms' tumor


Hepatic neoplasm in a 9 mo old:

Although rare in children this age, an hepatic neoplasm (malignant or benign) can cause an asymptomatic abdominal tumor and must be considered in a young infant with an asymptomatic RUQ abdominal mass. Jaundice may be a feature, but the lack of jaundice does not rule out this diagnosis.


Hydronephrosis in a 9 mo old?

An obstruction at the uretero-pelvic junction can lead to hydronephrosis and a palpable kidney, sometimes manifesting as a flank mass. In a newborn, a multi cystic kidney may cause such an obstruction.


What can hydronephrosis causing a 6 cm palpable mass present with?

While possibly asymptomatic, it would usually present with a UTI.


When is neuroblastoma usually diagnosed?

Neuroblastoma is the most frequently diagnosed neoplasm in infants - more than half of patients present before age 2.


How might a child with neuroblastoma present?

Tumor may present as a painless mass in the neck, chest or abdomen. Children with an abdominal neuroblastoma may be asymptomatic, however, they may also appear chronically ill and may have bone pain from metastases to the bone marrow or skeleton. Fever, pallor, and weight loss are frequent presenting symptoms.


When is neuroblastoma a likely diagnosis?

In an infant younger than a year of age who has an asymptomatic RUQ abdominal mass and pallor and no jaundice.


What is a teratoma?

A rare malignant tumor.(it is rare in children)


What might a teratoma present as?

It may present as a painless abdominal mass without other sx or it may cause pressure effects on neighboring structures resulting in abdominal or back pain, nausea, vomiting, constipation, and/or urinary tract symptoms.


When is Wilms' tumor (nephroblastoma) a likely diagnosis?

In a child with an asymptomatic RUQ abdominal mass who has no lymphadenopathy or jaundice on exam and who is growing and developing normally.


When are Wilms' tumors often discovered?

By the parents or on routine examination.


What are some features of Wilms' tumor?

The masses are generally smooth and rarely cross the midline.


What sx are associated with Wilms' tumor?

Associated sx occur in 50% of patients and include abdominal pain and/or vomiting; patients may also be hypertensive.


What is the median age of diagnosis of Wilms' tumor?

Median age of diagnosis is three years old.


What symptoms can a hepatic abscess cause?

Fevers, abdominal pain, abdominal mass, malaise and anorexia.


What are three recommendations for introducing difficult news?

1. First assist the family in working through their emotions; then the family may be ready for more information and plans.
2. Sometimes starting out with science, in a non-emotional fashion, can assist the family: IF they intellectualize the diagnosis, they can receive information and later deal with the emotions.
3. The most imp. thing is to convey concern and support, while still making sure the family understands that the treatment decisions need to be made sooner, rather than later.


What can a CBC with differential tell us for a pt. with abdominal mass?

Helpful in IDing the extent of anemia and to look for cytopenia that may be associated with bone marrow infiltration.


What can catecholamine metabolites (VMA and HVA) tell us for a pt. with an abdominal mass?

Urine or serum VMA/HVA measures metabolites of catecholamines, which are elevated in neuroblastoma. This test is highly specific for neuroblastoma and can be 90-95% sensitive in its detection.


What can a chest X-ray tell us for a pt. with an abdominal mass?

A chest X-ray can identify metastases to the chest. Chest CT or MRI is necessary only if metastases are seen on x-ray.


What can a skeletal survey tell us for a pt. with an abdominal mass?

A skeletal survey can identify metastases to the bone.


What can an abdominal US tell us for a pt. with an abdominal mass?

An abdominal US will identify a mass, show the organ of origin and determine if the mass is solid, cystic or combined. (Purely cystic masses are less likely to be malignant)
US is the best choice for first imaging study.


What can an abdominal XRAY tell us for a pt. with an abdominal mass?

A plain film can identify the presence of a mass, and perhaps whether it has calcifications, it cannot reveal other important information about the mass. This film may be more urgent if there is any evidence of bowel obstruction from the mass. The plain radiograph is not the best imaging study to order first.


What can an abdominal CT tell us for a pt. with an abdominal mass?

It is best at revealing calcifications, and - importantly especially for a surgeon - shows the anatomy better than an US. It also reveals the consistency of the tumor. Allows evaluation of the lungs during the same study which is important in finding metastases.If a lesion is purely cystic, a CT is not needed -- which is why US is done first.


Prognosis of Stage 4S Neuroblastoma:

Favorable stage, even though it has metastasized. In infants less than one year of age, these tumors may spontaneously regress.
This is due to the unique nature of this tumor derived from embryonal cell lines.


Familial forms of Neuroblastoma:

There are familial forms but these only account for 1% of neuroblastoma cases. The familial form appears to be AD, with low penetrance.


What is penetrance?

It refers to the percent of individuals with a mutation that display the clinical effects of the mutation.


What does low penetrance indicate?

If the mutation causing familial neuroblastoma has low penetrance it means that many people who inherit the mutation will not have neuroblastoma.


Non-familial forms of Neuroblastoma:

Most cases of neuroblastoma are due to somatic mutations.


What are somatic mutations?

Mutations that arise in cells other than the gametes. Somatic mutations are not passed to the next generation.