CLIPP case 2. Infant well-childs (neuroblastoma, food, vaccines)

Question 1

Caloric requirement of health term babies in first 2 months of life

Answer 1

100 cal/kg/day

115 for preterm and 150 for VLBW

Question 2

Moro reflex

Answer 2

• Abrupt change in the infant’s head position -> symmetric abduction and extension of the arms followed by adduction of the arms, sometimes with a cry
• Disappears by 4 months
• Used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries

Question 3

Normal infant rashes

Answer 3

Acne and seborrheic dermatitis

Question 4

Primitive reflexes present at birth

Answer 4

Moro (4mo), palmar grasp (3mo), plantar grasp (8mo), Asymmetric tonic neck/fencing (6mo), Babinski (2yr)

Question 5

Four domains of developmental milestones

Answer 5

Gross motor, fine motor, language, social

Question 6

Gross motor milestones (90%, 50-90%)

Answer 6

2 months: lift head, 45 degrees
4 months: sit-head steady, roll over
6 months: roll over, sit-no support
9 months: stand holding on, pull to stand

12 months: stands alone, maybe walk

Question 7

Fine motor milestones (90%, 50-90%)

Answer 7

2 months: follow to midline, past midline
4 months: grasp raddle, follow 180 degrees
6 months: reach, look for dropped yarn
9 months: transfer cube, take 2 cubes

12 months: neat pincer grasp

Question 8

Language milestones (90%, 50-90%)

Answer 8

2 months: vocalize, laugh
4 months: laugh, turn to rattling sound
6 months: turn to rattling, turn to voice
9 months: single syllables, dada/mama

12 months: mama and dada specific, and 1 other word

Question 9

Social-emotional (90%, 50-90%)

Answer 9

2 months: smile response, smile spontaneous
4 months: regard own hand
6 months: work for toy out-of-reach, feed self
9 months: feed self, wave bye

12 months: hands book to read, points when wants, imitates activities, plays ball with examiner

Question 10

PEDS screening tool

Answer 10

• evidence-based
• used 0-8yo
• able to be performed at all well-child visits
• used to identify developmental delay and need for further w/u

Question 11

When can introduce solids foods

Answer 11

• Rice cereal, iron-fortified, as early as 4 months
• New food every 5-7 days (to identify allergies)
• Signs of readiness: Able to sit up and keep head up on own; Can manipulate pureed foods like rice cereal in mouth (will not spit it out)

Question 12

Vitamin D supplementation

Answer 12

Likely deficient unless drinking 1 quart (32 oz) per day (breast/formula/cows). If mostly or solely breast feeding, supplement with max 400 units per day via multivitamin.

Question 13

When do they sleep through the night

Answer 13

By 4-6 months

Question 14

Sleeping position

Answer 14

On back to prevent SIDS

Question 15

CDC vaccination schedule

Answer 15

See CDC

Question 16

By when should an infant double and triple its birthweight?

Answer 16

Double by 5 months

Triple by 12 months

Question 17

Red reflex

Answer 17

*Red/orange color reflected from the fundus through pupil when viewed through ophthalmoscope 10 inches from the patient
*Normal if symmetric coloration and no leukocoria
*Absence of a red reflex may indicate underlying abnormalities, including:
Cataracts
Glaucoma
Retinoblastoma
Chorioretinitis

Question 18

Acetaminophen and vaccines

Answer 18

May cause a lower antibody response, and should be administered only if absolutely necessary

Question 19

Anticipatory guidance

Answer 19

*Sleep: Place on back to prevent SIDS. Most babies sleep through night by age 4 to 6 months. Infants at 6 months of age usually sleep through the night and take two naps
during the day
*Car seat: Infants facing rear, in middle of back seat. The most effective car-seat restraint is a five-point harness. Children < 13 years should not sit in the front seat.
*Other: child care, tobacco exposure, childproof home, walkers not recommended

Question 20

Rectal exam in infant

Answer 20

Only when intra-abdominal, pelvic, or peri-rectal process suspected

Question 21

Neuroblastoma

Answer 21

• The most frequently diagnosed neoplasm in infants–more than half of patients present before age 2
• Presents as painless mass in the neck, chest, or abdomen
• Asymptomatic, or chronically ill with bone pain from bone marrow or skeleton mets. Fever, pallor, and weight loss are frequent presenting symptoms.
• Neuroblastoma is a likely diagnosis in an infant younger than a year of age who has an asymptomatic RUQ abdominal mass and pallor and no jaundice
• Normocytic anemia and small cell rosettes in the bone marrow
• Elevated urinary catecholamines
• Stage 4S disease carries a favorable outcome (infant <1yo)

Question 22

RUQ mass in a 9 month old

Answer 22

DDx:

• Neuroblastoma
• Wilms’ tumor (nephroblastoma)
• Teratoma
• Hepatic tumor
• Hydronephrosis

Question 23

By when should an infant double its birth length?

Answer 23

48 months (4yo)

Question 24

Developmental surveillance versus screening

Answer 24

*Surveillance: Comparing a child to expected behaviors by age. Not as sensitive or specific as screening
*Screening: Assessment using evidence-based tool to pick up developmental or behavioral abnormalities. PEDS (Parents’
Evaluation of Developmental Status) for birth to 8 years. May take place routinely during well-child visit or at any patient encounter
where there are concerns.

Question 25

Immunizations received by age 5

Answer 25

• DTaP x5
• IPV x4
• PCV13 x4
• Hib x3 or 4
• RotaV x2 or 3
• MMR x2 (age 1 and 5)
• VZV x2 (age 1 and 5)
• HepA x2 (12 and 18 months)
• HepB x3
• Annueal influenza: 6 mo - 19 yo, household contacts and caregivers, high-risk groups (asthma, lung or heart disorders, immune deficiencies). Kids < 9 years need two doses one month apart.

Question 26

Immunization reaction

Answer 26

• Fussiness and fever for 24 hours

* If persist >24 hours, or more serious, child should be seen right away

Question 27

When can you start plain water?

Answer 27

When infant is eating solid foods

Question 28

When can you introduce cow’s milk?

Answer 28

12 months. No earlier due to concern for colitis

Question 29

Feeding of 9 month-old infant

Answer 29

*Requires 100 calories/kg/day, with 75% from breast milk or formula
*Can eat strained foods (Stage 2) and feed
self with finger foods (toast, crackers, pasta, and banana)
*May start meats (small pieces chicken)
*Discuss choking hazards: no popcorn, grapes, hard candies, hot dogs, or jelly candies

Question 30

Wilm’s tumor

Answer 30

• May present as asymptomatic RUQ abdominal mass without lymphadenopathy or jaundice, growing and developing normally. *Masses generally smooth and rarely cross midline
• Associated symptoms in 50% of patients: abdominal pain, vomiting, hypertensive
• Median age at diagnosis is 3yo

Question 31

Teratoma (germ cell tumor)

Answer 31

• Very rare, malignant tumor, presents as painless abdominal mass with no symptoms (no jaundice, pallor)
• If there are symptoms, related to pressure effects on neighboring structures: abdominal or back pain, nausea, vomiting, constipation, and urinary tract symptoms

Question 32

Hepatic tumor

Answer 32

• Hepatoblastoma and benign liver tumors

* Rare but consider in a young infant with asymptomatic RUQ abdominal mass. +/- jaundice

Question 33

Hydronephrosis

Answer 33

• Obstruction at the uretero-pelvic junction -> hydronephrosis with palpable kidney -> flank mass.
• May be asymptomatic, although usually with UTI