Exam 1 Flashcards
(208 cards)
1
Q
Infants ____________ are best examined on the exam table
A
Under 6 months
2
Q
Infants ___________________ are best examined in parents’ lap due to anxiety towards strangers
A
Over 6 months
3
Q
Pediatric visit acronym: BUDS
Address with each encounter
A
B - bowels
U - urine - more frequently than adults
D - diet - breast vs formula, introducing foods, etc
S - sleep - schedule, feeding q3h overnight to avoid hypoglycemia
4
Q
Pediatric visit acronym: NEST
A
N - nutrition
E - elimination
S - sleep
T - Track child’s growth and health (milestones, learning, etc)
5
Q
Pediatric Nutrition Acronym: Na.Vi.Ga.Te.D.
A
Na - Natural foods (types/quantities, fruits, vegetables, protein sources, fats)
Vi - Vitamins (evaluate for deficiencies, especially IRON sources d/t risk for dev delay)
Ga - Grains and Added sugar and salt (amount of whole grains, added salts/sugars to monitor for obesity)
Te - Teeth and gum care (fluoride, teeth brushing, prevent cardiac issues)
D - Dairy consumption (too much leads to IRON deficiency d/t it binding and not properly absorbing, leading to anemia and dev delay)
6
Q
Elimination Clinical Pearls
A
Stool and urine elimination is a helpful indicator of health
Educate on normal vs not normal
John Hopkins Stool Color Guide Reference
Evaluate for rectal stenosis as needed
7
Q
John Hopkins Stool Color Guide
- Normal Breast Fed
- Normal Formula Fed
- Meconium
- Abnormal w/ liver issues
- Dairy Intolerance
A
Normal Breast Fed - mustardy, seedy d/t high level of absorption by baby
Normal Formula Fed - Darker brown/green/yellow, more chunky
Meconium - black poop for first 1-2 days after birth, ABNORMAL if persists beyond three days
Abnormal liver issues - white, pale yellow, chalky grey color (biliary atresia)
Abnormal dairy intolerance - Rectal irritation with small blood staining. Formulas including Enfamil and Similac contain dairy.
8
Q
Sleep Clinical Pearls
A
Inquire about: Positioning - sleep on back Quality/Quantity Sleep Routines Sleep Safety - Avoid soft bedding, supine position, no extra pillows/blankets, use pacifier
9
Q
Sleep per day for: Newborn (0-3 mo) Infant (4-12 mo) Toddler (1-2 yr) Preschool (3-5 yr) School age (6-12 yr) Teen (13-18)
A
Newborn - 14-17 hours Infant - 12-16 hours Toddler - 11-14 hours Preschool - 10-13 hours School age - 9-12 hours Teen - 8-10 hours
10
Q
PE approach for Infant, toddler, preschooler, school age, adolescent
A
Infant - lying in parent’s arms, eyes/ears/mouth at end of exam, heart/lungs when child is sleeping/quiet, distract with older infants.
Toddler - minimal contact, allow child to look at and touch equipment, heart/lungs first then head to toe.
Preschooler - Similar to toddler, especially allow child to touch equipment
School age - Respect privacy, explain steps beforehand
Adolescent - Explain findings, respect privacy
11
Q
Infant Vital Sign Parameters HR Resp BP Temperature
A
HR - 100-160
Resp - 30-60 for 0-6 mo; 24-30 for 6-12 mo
BP - not checked
Temperature - 98.6F
12
Q
Child Vital Sign Parameters 1-11 years HR Resp BP Temp
A
HR - 70-120
Resp - 20-30 for 1-5yo; 12-20 for 6-11yo
BP - 90-110/55
Temp - 98.6
13
Q
Teen Vital Sign Parameters HR Resp BP Temp
A
HR - 60-100
Resp - 12-18
BP - 110-135/65-85
Temp - 98.6F
14
Q
Measurements of the Pediatric Patient
A
Growth charts for length, weight, and head circumference until 2yo
Temperature, weight, length, head circumference, HR, Resp, BP
15
Q
Weight loss patterns - Neonates
A
Lose up to 10% body weight within the first week
Regain birth weight by 2 weeks of age (gain 20-30g per day)
16
Q
Weight Measurement Infant (6 mo and 12 mo weight gain)
A
Infants DOUBLE their birth weight by 6 mo
Infants TRIPLE their birth weight by 12 mo
17
Q
Growth Chart for Weight
A
5th-85th percentile is WNL
FTT if weight/height decreases by 2+ major percentiles, or if below 3-5%
- Weight decreases first, then length, then HC
18
Q
How to obtain weight measurement
A
weigh in nude or clean diaper
Round to nearest 0.01 kg (or 1/2 oz)
Weigh twice for accuracy
Use standing scale if over 3 yo
BMI - don’t measure until 24 mo visit (results skewed prior to 2 yo)
19
Q
WHO vs CDC Growth Charts
A
WHO - 2-98 percentile considered normal; use until 24 mo.
CDC - 5-85 percentile considered normal; use for ages 2-20
20
Q
Measuring length/height
A
Average length is 50 cm at birth
Increases by 50% by year 1
Doubles by year 4
Triples by year 13
Increases by 1” per month during first 6 months; then by 0.5” from 6-12 mo
R/o familial short stature, constitutional delay, endocrine or bone disorders, puberty delays, etc.
21
Q
How to measure length
A
Supine until able to stand (24 mo)
>2 yo - remove shoes
Measure x2 for accuracy
If child falls off growth chart grid, requires work-up
22
Q
Head Circumference Growth Chart
A
Occipital frontal circumference Avg at birth is 35 cm Grows by 12 cm by 12 mo Measure each visit until 24 mo *** HC should correlate to child's length Microcephay - <10th percentile Macrocephaly - >90th percentile
23
Q
How to measure head circumference
A
Measure x2 for accuracy
Round to nearest 0.1 cm or 1/8”
Measure over largest circumference of head - occiput and above eyebrows
24
Q
Blood Pressure Measurements
A
Start monitoring at age 3 (using appropriate cuff size)
Monitor annually unless patient has risk factors (obese, on meds that cause HTN, renal dz, DM, COA)
HTN dx after multiple measurements over time, in >95th percentile on 3 different visits.
25
2 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)
Social/Emotional - smile, briefly calm self, looks at parent
Language - cooing, gurgling, turning head towards sound
Cognitive - pays attention to faces, follow objects with eyes, recognizes people at a distance, acts bored if activity doesn't change
Movement/Physical - hold head up, push up when on tummy, smoother movements with arms and legs
26
2 Month Milestone Red Flags
```
Not responding to loud sounds
Not watching moving objects
Not smiling at people
Not bringing hands to mouth
Unable to hold up head when pushing up on tummy
```
27
4 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)
Social/Emotional - smiles spontaneously especially at people; play with people and cries when they stop; copies movements and expressions
Language/Communication - babble with expressions, copies sounds, cries in different ways (hunger, pain, tired), laughing
Cognitive - happy or sad, responds to affection, reaches for toys with hand, uses hands and eyes together, follows things with eyes, watches faces closely, recognizes familiar faces at a distance
Movement/Physical - holds head steady while unsupported (HEAD LAG IS A RED FLAG), roll from belly to back, lift head to look around when on belly, brings hands to mouth
28
4 Month Milestone Red Flags
```
Not watching moving objects
Head lag
Not smiling at people
Not able to hold head steady
Not cooing or making sounds
Not bringing things to mouth
Not pushing down with legs when feet are on hard surface
Trouble moving one or both eyes in all directions
```
29
6 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)
Social/Emotional - knows familiar faces compared to strangers, play with others especially parents, responds to other emotions and is happy, looks at self in mirror
Language - responds to voice, strings vowels together when babbling (ah, eh, oh), takes turns with patients making sounds, responds to name, shows joy and displeasure, begins to say consonants (jabbering with M and B)
Cognitive - looking around, brings objects to mouth, curiosity towards objects out of reach and tries to get, pass things from one hand to the other.
Movement/physical - rolls in both directions, sitting without support, when standing is able to support weight on legs and maybe bounce, rocks back and forth, crawling backwards before moving forwards (number 6 looks like figure sitting)
30
6 Month Milestone Redflags
```
Not trying to grab things within reach
No affection towards caregivers
Not responding to sound around them
Difficulty getting things to mouth
Not making vowel noises (ah, eh, oh)
No rolling over in either direction
Not laughing or making squealing sounds
Stiffness, tight muscles
Very floppy, like a rag doll
```
31
9 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)
Social/Emotional - afraid of strangers, clingy with familiar people, favorite toys
Language - understands NO, different sounds (mamamama, bababa), copies sounds/gestures of others, points with fingers
Cognitive - watches path of something as it falls, looks for hidden things, peek-a-boo, puts things in mouth, smoothly moves object from one hand to the other, picks up small objects with thumb and index finger
Movement/physical - stands while holding on, can get into sitting position, sit without support, pulls up to stand, crawls with abdomen off the floor, bang objects together with both hands. (number "9" looks like a figure standing)
32
9 Month Milestone Red Flags
```
Not bearing weight on legs with support
Not sitting with help
Not babbling
Not playing games w/ back and forth play
Not responding to name
Not recognizing familiar people
Not looking where you point
Not transferring toys from one hand to another
```
33
12 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)
Social/emotional - shy/anxious around stranger, cries when mom/dad leaves, favorite toys and people, shows fear, hands book when wanting to hear story, repeats sounds/actions to get attention, puts our arm/leg to help with dressing, plays games (peek a boo, pat a cake)
Language - responds to simple spoken requests, uses simple gestures (shake head no, wave good bye), Sound changes in tone (sounds more like speech), says mama and dada and exclamations like uh-oh. Attempts to repeat words you say.
Cognitive - Explores in different ways (shaking, banging, throwing), easily finds hidden objects, looks at picture of named object, copies gestures, drinks from cup, brushes hair, puts things in/out of containers, more independent, pokes with index finger, follows simple directions (pick up toy)
Movement/physical - sits without help, pulls to stand, furniture surfing, few steps without holding alone, standing alone.
34
12 month milestone red flags
```
Not crawling
Not standing while supported
Not searching for hidden objects
Not saying single words (mama or dada)
Not learning gestures (waving hand, shaking head)
Not pointing to things
Loss of skill child has previously had
```
35
18 Month Milestones (Social/Emotional; Language; Cognitive; Movement/Physical)
Social/Emotional - hand things to others as play, temper tantrums, afraid of strangers, affection towards familiar people, simple pretend (feeding doll), cling to caregiver in new situation, points to show interest, explores alone with parent nearby.
Language - several single words, shakes head no, points to show something they want
Cognitive - knows what simple objects are (phone, brush, spoon), points to get attention, interest in dolls or stuffed animals, points to body parts, scribbles on own, follows one-step commands (sit down)
Movement - walks alone, walk up steps, run, pulls toys while walking, undress self, drink from cup, eat with spoon
36
18 Month Milestone Red Flags
```
Not pointing to show things to others
Unable to walk
Not knowing what familiar things are
Not copying others
Not gaining new words
Not knowing at least 6 words
Not noticing when caregiver comes/goes
Loses skill child previously had
```
37
2 Year Milestones (Social, Language, Cognitive, Physical)
Social - copies others, excited with other children, independence, defiant behavior, plays besides other children or with children (chase games)
Language - points to objects/pictures when named, knows names of people and body parts, 2-4 word sentences, follows simple instruction, repeats words overheard in conversation, points to things in books
Cognitive - Finds hidden things under multiple covers, sorting shapes/colors, completes sentences/rhymes in favorite books, builds towers of 4 blocks, uses one hand more than the other, follows two-step instructions, names items in picture books.
Physical - stands on tiptoes, kicks balls, run, climbs independently, up and down stairs, throws ball, copies lines and circles.
38
2 Year Milestone Red Flags
```
Not using 2-word phrases
Not knowing what to do with common objects (tooth brush, silverware)
Not copying actions/words
Not following simple instructions
Not walking steadily
Loses skill child previously had
```
39
3 Year Milestones ( Social, Language, Cognitive, Physical)
Social - copies others, shows affection for friends, takes turn in games, shows concern for crying friend, understands "mine" "his" and "hers", wide range of emotions, less separation anxiety, upset with major changes to routine, dresses/undresses self
Language - follows instruction with multiple steps, name most familiar things, understands words like in/on/under, says name age and sex, possessive nouns and plurals (I, me, we, you), carries on 2-3 sentence conversations
Cognitive - uses toys with buttons/levers/moving parts, plays with dolls/animals/people, small puzzles (3-4 pieces), draw circles, turns book pages, builds 6 block towers, screws/unscrews jar lids, turn door handle
Physical - climbs, runs, tricycle, stairs with one foot per step
40
3 Year Milestone Red Flags
```
Troubles with stairs/falling down
Drooling
Unclear speech
Not speaking in sentences
Not understanding simple direction
Not playing pretend/make-believe
Not playing with other children
Not making eye contact
Losing skills child once had
```
41
4 Year Milestones (Social, Language, Cognitive, Physical)
Social - Enjoys new things, plays mom and dad, more creative with make-believe play, rather play with others than self, cant tell what's real vs make-believe, talks about interests
Language - knows basic grammar rules, sings a song or rhyme from memory, tells stories, say first and last name
Cognitive - names colors/numbers, counting, starting to understand time, remembers parts of a story, understands difference between same and different, draw person with 2-4 body parts, uses scissors, copy some capital letters, plays board/card games, predicts what will happen in a book
Physical - hops and stands on one foot, catches a bounced ball, pours/cuts food with supervision
42
4 Year Milestone Red Flags
```
Can't jump in place
Trouble with scribbling
No interest in interactive games/make believe
Ignores other children
Resists dressing/sleeping/using toilet
Can't retell a favorite story
Doesn't follow 3-part commands
Doesn't understand difference between same and different
Not using "me" and "you" correctly
Speech is not clear
Loss of skill child once had
```
43
5 Year Milestones (Social, language, cognitive, physical)
Social - pleasing friends, agree with rules, sing/dance/act, aware of gender, can tell what's real vs make-believe, more independence, demanding and cooperative at times.
Language - clear speech, simple story telling with full sentences, future tense, says name and address
Cognitive - counts 10 or more things, draw a person with 6+ body parts, print some letters/numbers, copies triangle and other shapes, knows about everyday things (food/money)
Physical - stands on one foot for 10+ sec, hops, skips, somersault, uses fork/spoon/knife, uses toilet on own, swings/climbs
44
5 Year Milestone Red Flags
```
Not showing wide range of emotions
Shows extreme behavior (fear, aggression, shy, sad)
Withdrawn, not active
Not responding to people
easily distracted
unable to tell real vs make-believe
Can't give first and last name
Cant use plurals or past tense correctly
Not talking about daily activities/experiences
Not drawing pictures
Can't brush teeth, wash hands, or get undressed without help
Loses skill child once had
```
45
Premature Infants Adjusted Age
Premies may demonstrate delayed growth/attainment of developmental milestones
Always use adjusted age to evaluate growth and development for premature infants
Calculate by subtracting number of weeks infant was premature from the infant's chronologic age.
46
Adjusted age for premature infant born at 30 weeks' gestation at 4 month wellness visit
1.5 months old
| 4 months minus 10 weeks
47
Approach to Developmental Surveillance and Screenings (6 steps)
1. Review checklists and developmental history
2. Ask concerns
3. Assess strengths and risks
4. Observe child
5. Document
6. Obtain and share results with others (educators, WIC providers, home visitors, etc)
48
Developmental Surveillance vs Screening
Surveillance - "do you have concerns about development/behavior/learning?"
Screening - standard test to identify those at risk. Done with surveillance concerns and at specific routine visit. Determines need for further evaluation.
49
When to do standardized developmental screenings?
9, 18, and 30 months
50
When to do autism screening?
18 and 24 months
51
Denver II Screening Test
Cog & motor development
52
M-CHAT Screening Test
ASD
53
Vanderbilt Screening Test
ADHD
54
Pediatric Symptom Checklist Screening Test
Mental Health
55
ASD Facts
Begins early childhood and is a life-long disorder
Spectrum, ranging in severity
Delays may present differently at various ages
Child can develop typically, and then regress around 2 years of age
56
Autism Core Developmental Delays (3 areas)
Social communication (verbal and non-verbal)
Social interaction
Repetitive behaviors
57
ASD Treatment
NO CURE
Early intervention is key to improve child's functioning.
Multidisciplinary treatment:
- Applied behavioral analysis
- OT
- ST
- Sensory integration
- Alternative/complimentary treatment
*** Behavioral Treatment of a Medical Diagnosis***
58
ASD Incidence
1: 27 boys
1: 116 girls
Occurs across all races, ethnic, and SES groups, BUT minority groups are diagnosed later and less often
59
Average age of ASD diagnosis
Age 4, but can be detected earlier in life
60
ASD Risk Factors
Genetics
Older parents
Parents w/ child w/ ASD have 2-18% chance of having a second child w/ ASD
Correlation of ASD in identical and fraternal twin studies
VACCINES ARE NOT A RISK FACTOR
61
ASD Communication Red Flags
- Delayed speech and language
- Echolalia
- Not pointing
- Not using gestures
- No pretend play
62
ASD Social Interaction Red Flags
- Avoids eye contact
- Prefers solitary play
- not responding to name by 12 mo
- Not understanding personal space
63
ASD Behavioral Red Flags
- lines up toys
- obsessive interests
- rigid routines
- flapping hands
- frequent rocking or spinning
64
ASD Traits - 0-6 mo
Lack of responsive Smile
| Impaired social use of eye contact
65
ASD Traits - 6-12 mo
Impaired understanding and use of gestures
| Lack of language and speech
66
ASD Traits 12-18 mo
Lack of showing or pointing out objects/interests
Failure to offer comfort to others/friends
67
ASD Traits 18-24 mo
Lines up toys obsessively
| Enjoys non-functional play
68
ASD Traits 3yrs
Preference for solitary activities
| Speech can be formal or repetitive
69
ASD Traits 4 yrs
Pronoun reversal
| Lack of imaginative play
70
ASD Traits 5 yrs
Limits interaction with others
Not interest in attention from others
Unaware of others
71
ASD psychiatric comorbidities
```
ADHD - 30-60%
Anxiety - 11-40%
Depression - 7% kids; 26% adults
Seizures - 30%
Tourettes
```
72
ASD GI comorbidities
Constipation
GERD
Abd pain
Diarrhea
73
ASD Sleep Comorbidities
Nightmares 50%
Sleepwalking 50%
Insomnia50%
74
ASD autoimmune comorbidities
DM
| RA
75
ASD Screening Guidelines
- complete developmental screening at every well child visit starting in infancy
- Complete specific MCHAT ASD screen at 18 and 24 months
- If positive, refer for further testing to establish diagnosis (ADOS test for autism)
76
ASD ALARM acronym
A - autism is prevalent (know statistics)
L - listen to parents (parents usually express their concern)
A - act early (screening and surveillance)
R - refer immediately, do not wait
M - monitor (follow-up, educate, advocate)
77
M-CHAT Screen
ASD screen completed at 18 and 24 mo
2-stage parent-reported screening tool to assess risk of ASD
- 20 yes/no questions, takes 5-10 min
78
Referral and Medical Tests for ASD
Role out other causes of developmental delay
- Audiology - r/o hearing problems as cause of delayed speech
- Lead screening - r/o other causes for PICA
- Genetics - provide rationale for delayed milestones
- Neurology - EEG to r/o seizures (mimics lateral gaze)
79
ASD Diagnosis
PCP screens for possible ASD and only qualified providers can DIAGNOSE
- psychologist, psychiatrist, developmental pediatrician, neurologist
DSM-V criteria for diagnoses
80
ASD Tips for Conducting a Medical Visit
```
Simple and direct statements
use toys and pretend play
Rewards and reinforcements
decrease wait time
Structured/smooth visit
Visual aids with pictures
Have parent participate in assessment
Limit people in exam room and interruptions
Control noise level to create a quiet room
```
81
Newborn follow-up with PCP
D/C from hospital in:
<24H; f/u 2 days old
1-2 days; f/u by 4 days old
2+ days; f/u by 5 days old
Address weight, feeding, maternal health, bilirubin
82
Newborn Screening
Conducted on every baby born in the US, and is considered a public health service.
Conditions screened for varies by state and decided by the public health department
Recommended Uniform Screening Panel (RUSP) - guide of conditions to screen for (35 core conditions with 26 secondary conditions)
FREE OF CHARGE
83
Timing and collection of Newborn Screen
Heel stick
Important to do between 24-48 hours of life; some conditions aren't detected until over 24 hours old
10-14 days for results, PCP follows up with results
84
Newborn screening results
Normal/Negative
- no further action
Borderline
- must repeat
Markedly out of Range
- referral to ER; metabolic specialist
Positive
- immediate response required
POSITIVE SCREEN DOES NOT CONFIRM CONDITION, REQUIRES FURTHER TESTING
85
Neonatal Jaundice - Pathophysiology
Newborns have high Hct, but RBC have shorter life leading to high rate of hemolysis.
Hemolysis releases unconjugated bili into the blood.
NB liver inefficient at conjugating bili and excreting to GI tract.
Often develops within the firs 2-7 days of life then improves. Pathologic if persists beyond one week.
Can be neuro toxic if bili levels build up (crosses BBB) - leading to Kernicterus and cause damage to basal ganglia.
86
Pathologic Neonatal Jaundice
Onset - <24H life and takes over 1 week to resolve
Conjugated bilirubin
Fast rise in bili levels
87
Physiologic Neonatal Jaundice
Onset - after 72H and resolves within one week
UNconjugated bilirubin
Slow rise in bili levels
88
Primary Prevention Neonatal Jaunice
Breast milk - promotes reabsorption and excretion of bilirubin in stool
Promote 8-12 feedings per day to prevent jaundice (feedings q2-3H)
If mom is not producing enough milk supplement with formula
89
Neonatal Jaundice - Determining Risk
Calculating risk is most important step and guides necessary follow-up
Based on age (date and time of birth)
Date and time of serum bili sample collection
Risk rated low to high
90
Intervention of neonatal jaundice based on risk
Low - no intervention
Medium - increase feeding frequency, natural sunlight for baby, repeat testing in 24H
High - hospital referral, phototherapy, and all of above interventions. F/u within 2 days of hospital discharge.
Outpatient - evaluate weight, stools, voiding, intake, and total bili level
91
High Risk of Jaundice
Elevated total bili at discharge from hospital
Jaundice within first 24 hours of life is often pathologic
ABO incompatibility or positive Coombs test
G6PD deficiency
preterm (35-36 week gestation)
East asian race
Exclusive breast feeding (with poor milk supply)
92
Coombs Test
Mothers antibodies attacking baby's RBCs d/t Rh or ABO incompatibility
93
Kernicterus
A bilirubin encephalopathy
-Unconjugated bilirubin is fat soluble and can cross the
blood brain barrier resulting in damage to the basal
ganglia
-Prognosis is based on timing of diagnosis. Results vary
from full recovery to significant neurological harm.
94
Breastfeeding Recommendations
Exclusive breast feeding for first 6 months, then at 6 mo introduce other foods
Breast feeding should continue for the 1st year then as long as mutually desired
95
Breastfeeding Keys to Success
Early initiation
Feed 8-12 times per day in the beginning (q2-3h)
Follow feeding cues and do not wait for cry before feeding
Positioning properly
Avoid pacifiers and supplements
Support and encouragement, relaxation
96
Breastfeeding weight patterns
More rapid weight gain in the first 2 months, then less over the next 3-12 months
Dip in birth weight within first 10 days, then is regained by week 2
97
Average elimination in newborn
6-8 wet diapers
| 2-5 stools per day
98
Formula Feeding Guidelines
ONLY breastmilk or formula until 12 months
Whole milk after 1 yr
2% milk after 2 yrs
(milk binds with iron and can lead to anemia)
99
Formula Safety Tips
Never give infant water (electrolyte imbalances)
Don't warm in microwave
Never let infant sleep with bottle
Use only iron-fortified formula
Never keep formula at room temp for >2H
Discard bottle after 1 hour if feeding has begun
100
Feeding Documentation
Document frequency of feedings and how long to empty each breast.
Feeding is a cardiac stress test and can identify congenital heart disease if infant fatigues quickly or becomes cyanotic with feeding
101
Caloric Intake for Newborns
Infant requires 110-120 kcal/kg/day minimum
| Document at each visit
102
Vitamin D for Infants
Supports brain growth
Supplement with 400 IU daily for infants that are exclusively or partially breastfed
Formula is supplemented with adequate amounts
Levels can be very low in children with autism
103
Vitamin K for Infants
Prevention of hemorrhagic disease (unable to make their own vit B and is not shared by mom, leading to blood not being able to clot properly)
0.5-1.0mg IM in immediate newborn period
50% with vit K deficiency bleeding will have a brain bleed
Babies that do not get Vit K at birth are at risk of bleeding until 6 mo
104
Iron for Infants
Breast-fed infants require supplementation at 6 months (iron fortified cereal)
Formula-fed infants receive adequate supplementation
105
Fluoride for Infants
No longer recommended at under 6 mo age
106
Pacifier Use
Decreased success with breastfeeding if started too early (within first 3-4 weeks)
Only use in neonatal period for pain relief or to enhance oral motor function
Reduced rates of SIDS when used during sleep
Use during sleep/naps after breastfeeding is well established, after 3-4 weeks of age
107
Umbilical Cord Care
Just keep clean and dry, do not apply alcohol on cord
Fold diaper below cord to prevent urine from soaking it
Usually falls off within first 2-3 weeks
108
Introduction to Foods and Juice
Foods - starting at 6 mo; offer wide variety of healthy foods and textures; FE fortified cereal (not rice cereal)
Juice - no more than 1-5 oz/day, white grape is best tolerated, apple/pear linked to carbohydrate malabsorption and has high sorbitol content which helps constipation, citrus juice after 1st year (harder on GI tract)
Cup - use cup around 8-11 mo starting with a spout.
Soft finger foods - 8-10 mo
Mashed table foods - 8-12 mo
>9 mo- offer healthy snacks 2-3x/day in addition to three meals
109
Introduction to food - Toddlers 1-3
Eat table foods in highchair or booster
Avoid high sugar/high fat snacks
Encourage self feeding, finger foods, spoon
Limit bottle and wean at 18 mo
Do not force child to eat if picky, respect strong dislikes and reintroduce later
110
Preterm
<34 weeks
111
Late Preterm
34-36 weeks
112
Term
37-42 weeks
113
Post-term
42+ weeks
114
NB Assessment - Size
Term AGA (appropriate gestational age) - 5 lb 12 oz-8 lb 12 oz
SGA - <10th percentile
LGA - >90th percentile
115
NB head assessment
Exam from above
| Molding is common and resolves within the first week
116
Microcephaly
2-3 SD below mean
Increased risk of learning disabilities
Etiology - genetics, poor nutrition, infection, fetal exposures
S/S - early fontanelle closure, prominent cranial sutures, downward sloped forehead, skull asymmetries, high arched palate
Requires referral
117
Macrocephaly
2-3 SD above mean
Etiology - hydrocephalus, intracranial lesions, neurofibromatosis, familial (benign)
Progressive/excessive head growth, wide suture lines, delayed fontanel closing, signs of increased intracranial pressure, ocular abnormalities, cafe-au-lait spots, skeletal dysplasia
Requires referral
118
Fontanelles
Soft and flat
Check in upright position
Anterior - diamond shaped, closes between 6-24 mo
Posterior - triangle shaped, closes between 2-3 mo
119
Sutures
Approximated and mobile
May be split up to 1 cm
Should remain open until 2-3 yo
Premature closure - craniosynostosis (get skull x-ray)
120
Brachycephaly
flat/short head
121
Plagiocephaly
flat spot on head
122
Scaphocephaly
long narrow skull
123
Caput Succedaneum
Most common birth trauma
edema CROSSES suture lines
Resolves within several days
Caused by edema, can see finger indentation when pressed on
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Cephalohematoma
Collection of blood bound by sutures
Does NOT CROSS suture line
Does not require dx test, weeks to months to resolve
May lead to high bili levels
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NB Face Assessment
Symmetry, spacing, features
Facial movements during crying
Facial nerve palsy - common during birth w/ forceps use (resolves in days to months)
126
NB Eye Assessment
Symmetry/formation, corneal light reflex, red reflex, pupil size equality, and pupillary reflex
Position - assessed by extending a line from inner eye to outer canthus towards ear
Otoscope exam is very difficult w/ NB
Hearing screen - eyes blink w/ sudden sharp sound
Cross eye/wall eye is normal until 4 mo
Tear formation starts at 2-3 mo
NL duct is not patent until 5-7 mo so it is common to have purulent/mucoid eye drainage
Iris color is dark gray/blue/brown at birth, and will reach final pigment at 6 mo
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NB Nose Assessment
Obligate nasal breathers for first 2 years of life
NB sneeze a lot (normal reflex)
Only maxillary and ethmoid sinuses are present at birth, and palpating in NB is not helpful
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NB Mouth Assessment
Inspect mucosa, tongue, gums, palate, tonsils, and posterior pharynx (best seen while crying)
Teeth in NB - 1:2,000 births (often w/ cleft palate, and requires removal)
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NB Clavicle Assessment
Common bone bx in NB (especially in LGA)
| Greenstick fx - asymptomatic, decreased movement, deformity, crepitus, discoloration, asymmetry
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NB Neck Assessment
inspect for masses/adenopathy (extremely uncommon in NB)
Assess neck mobility
very short necks, and lengthens by 3-4 yo
131
NB Chest Assessment
Chest wall is thin
Enlarged breasts common d/t mother's estrogen and usually disappears by 2 weeks (may also see milky fluid from nipples - Witch's Milk)
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NB CV Assessment
PMI in 4th ICS (not the 5th like in adults)
Check pulses - brachial, radial, femoral
Weak associated with COA
Bounding pulses associated with PDA (patent ductus arteriosus)
Cap refill is <1 sec
Murmurs in babies - flow murmurs (d/t PDA and tricuspid regurg)
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NB Abdomen Assessment
Sequence same as adults
Assess umbilical cord remnant, ascultate bowel sounds when baby is quiet
No need to routinely check rectal tone in NB (may beck for stenosis in NB w/ constipation)
134
NB Female Genitalia Assessment
Can be prominent d/t maternal estrogen levels, and may have milky white vaginal discharge w/ slight blood tinge for first several weeks (not cause for concern)
Note vaginal opening (can get vaginal adhesions)
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NB Male Genitalia Assessment
Foreskin of NB is nonretractable at birth
Milk testes down to scrotum or inguinal (3% not descended)
Common scrotal masses - hydroceles and inguinal hernia (transillumination test)
- Hydroceles transilluminate and can not be reduced
- Hernias - usually reducible and do not transilluminate, require surgery
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NB Cryptorchidism
Undescended testes
Dx in NB period, and may lead to CA, torsion, and infertility in future if not fixed
Must refer to urology if unable to milk testes to scrotum (if unsure, refer)
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NB Nervous System Assessment
Inspect motor tone
Palpate tone through passive ROM of major joints
Reflexes
- NB - palmar, plantar grasp, moro, asymmetric tonic neck, positive support, ana, babinski +
- Infancy - Triceps, brachioradialis, abdominal reflexes starting at 6 mo
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NB Babinski Sign
Plantar stimulation causing dorsiflexion of big toe and fanning of others
Up to 10 beats are normal in NB and young infants, of sustained there may be a pathologic process
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Palmar Grasp Reflex
- Maneuver
- Normal Age
- Red Flag
- press finger on plantar surface and baby will flex fingers to grasp
- birth to 4 mo
- Beyond 4 mo indicates pyramidal tract dysfunction
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Plantar Grasp Reflex
- Maneuver
- Normal Age
- Red Flag
- Touch sole at base of toes and toes curl
- Birth to 8 mo
- Beyond 8 mo indicates pyramidal tract dysfunction
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Rooting Reflex
- Maneuver
- Normal Age
- Red Flag
- Stroke corner of mouth and mouth will open and head will turn towards stimulation
- Birth to 3-4 mo
- Absence indicates CNS disease
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Moro Reflex
- Maneuver
- Normal Age
- Red Flag
- Hold infant supported supine and abruptly lower about 2 feet, arms will extend, hands open, legs flex, baby may cry
- Birth to 4 mo
- Beyond 4 mo indicates neurologic disease (cerebral palsy), asymmetric response suggests fracture or brachial plexus injury
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Trunk Incurvation (Galant) Reflex
- Maneuver
- Normal Age
- Red Flag
- Support infant prone and stroke one side of back 1 cm from midline from shoulders to buttocks. Spine will curve towards stimulation.
- Birth to 2 mo
- Absence suggests transverse spinal cord lesion or injury, persistence suggests delayed development
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Landau Reflex
- Maneuver
- Normal Age
- Red Flag
- Support infant prone position, and head will lift up and spine will straighten
- birth to 6 mo
- Persistence = delayed development
145
Parachute Reflex
- Maneuver
- Normal Age
- Red Flag
- Suspend baby prone and lower head towards a surface, arms/legs extend in protective fashion
- Starts at 8 mo and does not go away
- Delayed start may predict future delays
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Positive Support Reflex
- Maneuver
- Normal Age
- Red Flag
- Hold infant around trunk and have feet touch surface; baby will partially bear weight and stand up for about 20-30 seconds
- Birth until 2-6 mo
- Lack of reflex suggests hypotonia; fixed extension suggests spasticity from neuro disease (cerebral palsy)
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Placing and Stepping Reflexes
- Maneuver
- Normal Age
- Red Flag
- Hold infant upright and have one sole touch table, hip and knee/foot will extend and step forward, alternate stepping occurs
- Birth (4 days after birth), and disappears at various intervals
- Absence may suggest paralysis. Breech delivery infants may not have this reflex
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NB Musculoskeletal Assessment
Palpate and inspect, particular attention to hands, spine, hips, legs, feet
Check gluteal folds
Check alignment of feet (correct feet to neutral position), refer to ortho if unable
Ortolani Test - hip dysplasia, (you feel a clunk as the femoral head enters the acetabulum; refer to ortho
Barlow Test - tests for the ability to sublux or dislocate an intact but unstable hip
- Positive sign indicates laxity, not dislocation.
- Follow closely, refer to ortho
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Seborrheic Dermatitis
- cradle cap; redness w/ greasy scales, occurs in 1st mo and is self limited; does not itch.
150
NB Transient vascular phenomena
Normal mottling look in NB
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Harlequin Color Change
- when laying on side, red on dependent side, blanching on other side. Lasts for 20 min and resolves with movement or crying. 2-5 days of life and up to 3 weeks
152
Cutis Marmorata
- Symmetric mottling of skin involving trunk and extremities in response to cold
153
Erythema Toxicum Neonatorum
- most common pustular eruption, appears in 2-3 days, flea bitten appearance, unknown cause
154
Transient Neonatal Pustular Melanosis
- 5% african american population, differentiate between ETN; these do not have surrounding redness and ruptures easily leaving a scale. Fades by 1 mo
155
Acne Neonatorum
- 20% NB, face, cheek, forehead. Hormones of baby/mom on sebaceous glands.
156
Milia
- pearly white papules, 50% NB. Spontaneously disappear
157
Advisory Committee on Immunization Practices (ACIP)
Committee that meets annually to review guidelines on US childhood immunization.
158
National Childhood Vaccine Injury Act of 1986
- Signed into law by Reagan in 1986
- goal to reduce potential financial liability of vaccine makers due to vaccine injury claims
- Compensates people injured by rare, vaccine-related adverse reactions, providing liability protection for vaccine manufacturers and administrators
- Provisions: Vaccine Adverse Event Reporting System, National Vaccine Program Office, Vaccine Information Sheets
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Vaccine Adverse Event Reporting System (VAERS)
Comanaged by CDC and FDA
Anyone can report; HCPs are required to report ADRs
Passive reporting; relies on reports that get sent in
Used to detect unusual/;unexpected patterns of reactions
Only tracks data, does not provide medical advice or judge the cause or seriousness of adverse reaction
160
Vaccine Information Sheets (VIS)
Information sheets provided prior to vaccination
HCP should document information for each VIS provided
Charting: edition date of VIS distributed, date the VIS was provided, date of administration, information on who administered vaccine, manufacturer/lot #
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Immunity
- definition
- passive
- active
Process of inducing immunity against a specific disease
- Passive: (given), protection by antibody or antitoxin produced by one animal or human and transferred to another. Ex: temporary protection, maternal antibodies to infant
- Active: (body makes); immunity after exposure to antigen (either natural infection or a vaccine); stimulates immune response.
162
Live vs Inactive Vaccines
Live - derived from wild viruses/bacteria. The virus is attenuated (weakened) in a lab then given to individual. Immune response to live vaccine is same as actual exposure.
*Can cause severe reaction especially in weakened immune system (immunosuppressed individuals, those w/ hx splenectomy)
Inactive - virus/bacteria is not live and does not replicate. Generally require multiple doses to gain full immunity.
* Can NOT cause severe disease in weakened immune systems
163
Vaccines for 17 diseases
1. Varicella (chicken pox)
2. Diphtheria
3. Influenza
4. Hep A
5. Hep B
6. Hib (Haemophilus influenzae type b)
7. HPV
8. Measles
9. Meningococcal
10. Mumps
11. Pneumococcal
12. Polio
13. Rotavirus
14. Rubella (german measles)
15. Shingles (Herpes zoster)
16. Tetanus
17. Pertussis (whooping cough)
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How to use vaccine schedule (4 tips)
1. Determine recommended vaccine by age
2. Determine recommended interval for catch-up vaccination
3. Assess need for additional recommended vaccines based on medical condition/other indications
4. Review vaccine types, frequencies, intervals, and special considerations
165
Chickenpox Vaccine
Varicella
166
Diphtheria Vaccine
DTaP
167
Haemophilus influenzae type B vaccine
Hib
168
Hepatitis A vaccine
HepA
169
Hepatitis B vaccine
HepB
170
Measles Vaccine
MMR
171
Mumps vaccine
MMR
172
Pertussis Vaccine
DTaP
173
Polio Vaccine
IPV
174
Pneumococcal Vaccine
PCV13 (prevnar)
175
Rotavirus Vaccine
RV
176
Rubella Vaccine
MMR
177
Tetanus Vaccine
DTaP
178
Hepatitis B Vaccine for Mother HBsAg - Negative
1 dose within 24 hours of birth (or at 1 month if premie)
179
Hepatitis B Vaccine for Mothers HBsAg - Positive
HepB vaccine AND hep B immune globulin within 12 hours of birth
- for premies <2,000g administer 3 additional doses for total of 4 beginning at 1 mo
- Test for HBsAg and anti-HBs at 9-12 months
- if series is delayed, test 1-2 months after final dose
180
Hepatitis B Vaccine for mothers with unknown HBsAg status
Treat is if mother is positive, but only give hep b immune globulin if mother comes back positive
*determine mother's HBsAg status as soon as possible
181
Hepatitis B Vaccine Series
Routine: 3 doses at birth, 1-2 months, and 6-18 months
Begin as soon as possible for those who did not receive vaccine at birth
Minimum age for final dose is 24 weeks
Minimum Intervals:
- Dose 1-2: 4 weeks
- Dose 2-3: 8 weeks
- Dose 1-3: 16 weeks
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Rotavirus Vaccine (RV) Series
Live oral vaccine
Two types; RV1 and RV5. Either is okay, no preference.
RV1: Rotarix
- 2-dose series at 2 & 4 months
RV5: RotaTeq
- 3-dose series at 2, 4, 6 months
*if uncertain on type of RV used, or if RV5 was used as any of the doses, default to 3 doses total.
Catch-up vaccination: do not start series at 15+ weeks; max age for final dose is 8 months
183
Adverse Reactions of RV (RV5 vs RV1)
RV5 - RotaTeq
- diarrhea, vomiting after 1 week
- OM, naso-pharyngitis, bronchospasm up to 42 days
RV1 - Rotarix
- cough, runny nose after 1st week
- Irritability/flatulence 31 days
184
DTaP Vaccination Series
- age
- series
- catch-up
For ages <7 years
5-dose series at 2, 4, 6, 15-18 months, 4-6 years
* dose 4 can be done as early as 12 months if there have been at least 6 months since previous dose
Catch up - dose 5 is unnecessary if dose 4 was given after 4 years of age and if there has been at least 6 months since dose 3
185
DTaP
- special situations
- adverse reactions
Special situations: wound management in children <7yo who have received at least 3+ doses, administer DTaP if more than 5 years since previous dose
Adverse Reactions
- local: pain/redness/swelling (especially after 4-5th doses)
- entire limb swelling does not contradict future doses
- Fever of 101F
186
Tdap Vaccine Series
- age
- Routine series
- For ages >7 yo; typically given at age 11
| - Routine Series: adolescents ages 11-12yo for first dose; pregnancy 1 dose given around 27-36 weeks
187
Tdap Special Situations
Wound management in ages 7+ with 3+ doses of tetanus containing vaccine:
- Clean/minor wounds: Tdap or Td if 10+ years since last dose
- All wounds: Tdap or Td if 5+ years since last dose
Tdap preferred over Td for those aged over 11 yo who have not previously received Tdap or who are uncertain if they have gotten vaccinated
Pregnant Adolescent - use Tdap
188
HIB Vaccination Series
- minimum age
- types
- series
- 6 weeks minimum age
- ActHIB, Hiberix, Pentacil, PedvaxHIB
- ActHIB/Hiberix/Pentacil: 4-dose series at 2, 4, 6, 12-15 mo
PedvaxHIB: 3-dose series at 2, 4, 12-15 mo
All HIB vaccines are interchangeable and can each be used as a booster, if different brands are used, child needs 3 dose series.
If child is unvaccinated at age 60+ months, and who are not considered high risk; no need to vaccinate
189
Pneumococcal Vaccination
- min age
- series
- catch up
- high risk children considerations
6 weeks minimum age for PCV13; 2 years minimum age for PCV23
PCV13: 4 dose series; 2, 4, 6, 12-15 mo
1 dose for 2-5 years if series is incomplete; no further doses for healthy children if first dose was administered after 2 yr.
Conditions high risk: heart dz, DM, lung dz, SCD, HIV, leukemia, etc
When both PCV13 and 23 are indicated, give 13 first. Never give both at same visit.
190
Polio Virus Series (IPV) <18 yr
- min age
- series
- minimum 6 weeks
| - 4 dose series at 2, 4, 6-18 mo, 4-6 years (final dose after age 4yr and must be at least 6 mo after 3rd dose)
191
Influenza Vaccine Series
- timing/series
- types of vaccines (3) with minimum age
- 2 doses after 6 mo; then 1 dose annually
- Inactivated Influenza vaccine (IIV) - minimum age 6 mo
- Live, Attenuated Influenza Vaccine (LAIV4) - minimum age 2 yrs
- Recombinant Influenza Vaccine (RIV4) - 18 years
192
Influenza vaccine special situations
Egg allergy w/ hives: give any influenza vaccine, annually
Egg allergy w/ angioedema/resp distress: any vaccine given annually and supervise in a medical setting.
193
When to avoid live influenza vaccine (LAIV4)
Hx severe allergic reaction
Receiving ASA/salicylate medications
Children under 2 yo, or ages 2-4 with hx asthma/wheezing
Immunocompromised or close contacts of caregivers who are immunocompromised
Pregnancy
Cochlear implant or CSF-oropharyngeal communication
Received recent influenza antiviral medication
194
MMR Vaccine Series
- minimum age
- routine series
- minimum age: 12 mo
- 2-dose series at 12-15 mo; and 4-6 yrs
(dose 2 can be given as early as 4 weeks after first dose
195
Varicella Vaccine Series
- minimum age
- series
- minimum age 12 mo
- 2 dose series, 12-15 mo; 4-6 years
* dose 2 can be given 3 mo after first dose
* can be given with MMR vaccine - MMRV (Proquad)
196
Hepatitis A Vaccine Series
- minimum age
- series
Minimum age - 12 mo
2 dose series w/ 6 mo minimum in between doses
197
HPV Vaccine Series
- minimum age
- series
- minimum age 9 yo, often recommended to start at age 11
- 2-dose series if started ages 9-14; w/ 6-12 mo interval in between
- 3-dose series if started after 16 yo; at 0, 1-2, then 6 months
198
Meningococcal Vaccine (ACWY)
- minimum age
- routine series
- special considerations
- min 2 mo for Menveo; 9 mo for Menactra
- 2-dose series; 11-12 years; 16 years
- First-year college students living in a res hall; or military recruit should get one dose if not previously vaccinated.
199
Meningococcal B Vaccine Series
- Shared clinical decision-making
| - 2-dose series
200
Pediarix Combination Vaccine
DTaP-HepB-IPV
201
Pentacel Combination Vaccine
DTaP/IPV/Hib
202
Kinrix/Quadracel Combination Vaccine
DTaP/IPV
203
Vacelis Combination Vaccine
DTaP-IPV-Hib-HepB
204
ProQuad Combination Vaccine
MMR/Varicella
205
Parental Vaccine Refusal & Role of HCP
Educate (make sure parent understands risk)
Take time to listen
Keep conversation going over each visit
Ask and answer questions; address parent's concerns
206
Vaccine Interval Tips
4 weeks = 28 days = 1 month
Intervals of >4 mo are determined by calendar months
Vaccines administered
207
Patient without vaccine records
HCPs should only accept written/dated records as evidence of vaccination (exception for PPSV23 and flu)
Administer recommended vaccines if immunization hx is incomplete or unknown
208
Reducing child's pain with a vaccine
- tasting something sweet reduces pain response; give small taste of sugar or breast milk several minutes before shot
- cooling spray or pain relieving ointment helps child
