Case 2 - CLIPP - infant well child checks

Question 1

Components of a well-infant visit

Answer 1

1. Interval history
2. Growth - HC, weight, height
   - babies are expected to regain birth weight by 2 weeks
   - double weight by 4-5 months
   triple weight by 12 months
   - double length at 48 months
3. Development - gross motor, fine motor, language, social
4. Diet - breastfeeding vs formula, supplementation
5. Social history
6. Physical exam
7. Anticipatory guidance - child care, sleep patterns, exposure to smoke, childproofing house, use of walkers, car seat safety
8. Immunizations

Question 2

Immunizations

Answer 2

DTap (5)
IPV (4)
Hib (3 or 4)
PCV (4)
MMR (2)
Varicella (2)
RotaV (2 or 3)
Hep A (2)
Hep B (3)
annual flu shots

Question 3

Infant nutrition

Answer 3

• Only breast milk or formula until 4-6 months
• breast milk is preferred, different formulas made of cows milk, soy or hydrolyzed cow protein
• breastfed infants need vitamind D supplementation
• transition to foods at 4-6 months, each food introduced one at a time, start with infant cereals, then move to other pureed foods

Question 4

Caloric requirements of infant

Answer 4

Term infants: 100-120 calories/kg/day
Preterm infants - 115-130
VLBW infants: up to 150 calories/kg/day

Question 5

Gross motor milestones

Answer 5

2 months - lifts head 45 degrees
4 months - sits with head steady, rolls over
6 months - sits without support, puts feet in mouth, no head lag
9 months - pulls to stand

Question 6

Fine motor milestones

Answer 6

2 months - follows to or past midline
4 months - follows 180 degrees, grasps rattle
6 months - reaches, looks for dropped item
9 months - takes 2 cubes, passes cube, neat pincer grasp

Question 7

Cognitive

Answer 7

2 months - vocalizes
4 months - laughs, turns to rattle
6 months - turns to voice, babbles
9 months - single syllables

Question 8

Personal-social

Answer 8

2 months - smiles responsively
4 months - regards own hand
6 months - works for toy, feeds self, stranger recognition
9 months - feeds self, plays pat a cake, waves bye bye, stranger anxiety

Question 9

Physical exam in infants

Answer 9

• growth evaluation
• general
• vital signs
• HEENT - anterior fontanelle, red reflex
• hips - ortolani and barlow maneuvers
• neuro - primitive reflexes (Moro, babinski)
• spine - sacral dimple or hair tuft

Question 10

Differential diagnosis for infant with abdominal mass

Answer 10

1. Neuroblastoma - most common neoplasm in infants, pts can be asx, tumor can spontaneously regress
2. Wilm’s tumor - RUQ mass without LAD or jaundice, can have vomiting or HTN
3. Teratoma - rare cancer, low on differential
4. Hepatic tumor - rare at this age
5. Hydronephrosis - obstruction at uteropelvic junction and palpable kidney

Question 11

Studies for abdominal mass

Answer 11

• CBC
• urinary vanillylmandelic acid/homovanillic acid - test specific for neuroblastoma
• chest x-ray for mets
• Technetium-99 bone scan
• bone marrow aspiration, biopsy

Question 12

Management of abdominal mass

Answer 12

referral to oncologist, tumor staging, family meeting, reseciton vs. observation, long term follow up