Intro to Peds Newborn/Infant Toddler

Question 1

Objectives

Answer 1

• Understand the components of a well exam during the newborn and toddler period
• Understand normal vs. abnormal patterns of feeding, sleep, elimination, growth and development
• Recognize signs and symptoms of common illnesses found in the newborn-toddler period

Question 2

Vaccinations

1. Hep B
2. MMR
3. Tdap
4. Rotavirus
5. Dtap
6. Hib
7. IPV
8. PCV
9. Varicella
10. Meningitis

Answer 2

Question 3

Newborn Well Exam

The AAP recommends well exams be performed during the following time periods?

Answer 3

• 2 wks
• 2, 4, 6, 9 mths
• 12, 18, 24, 30, 36 mths
• Then annually

Question 4

General Components

1. (1): concerns or questions, follow up on previous concerns, interval history
2. (1): change in family or social hx, parents work outside the home, parental support, daycare
3. (1): Nutrition, Elimination, Sleep, Behavior, Activities
4. (1): Social/Emotional, Language/Communication, Cognitive, Motor
5. (1): Head to Toe
6. ______ Guidance
7. Imm_______

Answer 4

1. History
2. Social/Family History
3. ROS
4. Developmental Surveillance
5. Physical Exam
6. Anticipatory Guidance
7. Immunizations

Question 5

Birth Weight Terms

• LBW =
• VLBW =
• ELBW =
• HBW =
• NBW =
• Females =
• Males =

Answer 5

• <2500gm
• <1500gm
• <1000, <750gm ILBW
• >4000gm
• 2.5-<4.0kg
• 2.8-4.0kg, avg 3.5kg (7lb 12 oz)
• 2.9-4.2 kg; avg 3.6kg (8lb)

Question 6

Gestational Age Terms

• Term =
• Premature =
• SGA =
• LGA =
• AGA =
• IUGR: describe less than optimal pattern of growth over a period of time - it is possible to be IUGR not ___

Answer 6

• completed 37 wks gestation till 42 wks
• less than 37 wks gestation
• <10th percentile
• >90th percentile
• 10-90th percentile
• possible to be IUGR not SGA

Question 7

Neonate Visit

(don’t have to memorize)

• First visit after ____
• Lots of history
• Maternal
  
  • Any in_____
  • Med____
  • Hos_____
  • P____ care
  • Maternal _____ type
  • F____ history
  • S____ status
• Labor and Delivery
  
  • weeks of _____
  • infant ____ type
  • type of _____
  • C_____
  • _____ scores
  • Group B ___ status

Answer 7

• birth
• Maternal
  
  • infections
  • medications
  • hospitalization
  • pre-natal
  • blood
  • family
  • smoking
• L/D
  
  • gestation
  • blood
  • delivery
  • complications
  • APGAR
  • Strep

Question 8

Neonate Visit

• Screenings
  
  • H_____
  • Ca_____
  • Transcutaneous b_____ (TCB)
  • S_____ bilirubin
  • J_____
  • Ph____therapy
• Measurements
  
  • Birth w____, l____, head _____, dis____ weight
• Interventions
  
  • Prophylaxis ___
  • Vitamin __
  • Hep __
  • Circum_____

Answer 8

• Screenings
  
  • Hearing
  • Cardiac
  • Bilirubin
  • Serum bilirubin
  • Jaundice
  • Phototherapy
• Measurements
  
  • weight, length, HC, discharge weight
• Interventions
  
  • Prophylaxis eye
  • K
  • Hep B
  • Circumcision

Question 9

Neonate Visit

• Ask about ______
• _____
  
  • Breast, Formula, or Both
  • Infants feed on demand every __-__ hrs
  • Need about __-__oz of breastmilk/formula per lb of body weight
  • Plot weight, monitor c____
• ____
  
  • On ___
  • In ___ crib/bassinet
  • # of hours
• _____: color, consistency, frequency

Answer 9

• concerns
• Feeding
  
  • 1-2hrs
  • 2-2.5 oz
  • curve
• Sleep
  
  • on back
  • in own crib
• Stooling

Question 10

Neonatal Stooling

• Breastfed infants
  
  • M_____ first 24-48 hrs, color is dark ____
  • Then _____, s____ changing to ____ color
  • Can stool after each _____
  • Tends to be very s___ or w______
• Formula fed infants
  
  • M_____ first 24-48 hrs
  • Then can be y____, t___, b_____
  • Tends to be ____ like peanut butter consistency
• **THERE SHOULD NEVER BE ____ IN THE STOOL**

Answer 10

• Breastfed
  
  • Meconium, dark
  • green, seedy, mustard
  • feeding
  • softy, watery
• Formula
  
  • Meconium
  • yellow, tan, brown
  • thicker
• BLOOD*! NEVERR

Question 11

Neonatal Vital Signs

1. RR
2. HR
3. HC
4. Length
5. Temp

Answer 11

1. 40-60
2. 120-160
3. 33-37cm (10th-90th)
4. 19-21” (48-53cm)
5. 97-100.3F

Question 12

Tone

• Observe their position at rest
  
  • Are they r____, are they fl____
  • Are their arms _____
  • Do they sit in a ___ leg position
• Move each major ____ through ROM
• Positions
  
  • Head ____
  • V_____ Suspension
  • V_____ Suspension

Answer 12

• Observe position at rest
  
  • rigid, flaccid
  • flexed
  • frog
• Joint
• Positions
  
  • Lift
  • Vertical
  • Ventral

Question 13

Primitive Reflexes

• _____ Grasp: Birth to 3-4 mths
• _____ Grasp: Birth to 6-8 mths
• S_____ Reflex: Birth-variable (3mths)
  
  • Holding onto a surface, allow one sole to touch the ground and see that the _____ leg will step _____

Answer 13

• Palmar
• Plantar
• Stepping
  
  • Opposite leg, step forward

Question 14

Primitive Reflexes

• Rooting Reflex (birth to 3/4 mths) =
• Moro Reflex (birth to 4 mths) =
• Tonic Neck Reflex (birth to 2 mths) =

Answer 14

• Turns head toward stimuli of cheek and begin sucking
• Startle response, arms extend out while legs flex
• Head turned to one side, Arm to which head is turned extend while the other flex

Question 15

Reflexes

What are they and when are they expected to go away?

1. Babinski
2. Blinking
3. Grasping
4. Moro
5. Rooting
6. Stepping
7. Sucking
8. Swimming
9. Tonic Neck

Answer 15

Question 16

Sensory/DTR/Cranial Nerves

• ____ Sensation
  
  • Flick hand or feet, look for child to withdraw and cry
• ____ ____ Reflexes
  
  • Are variable due to the corticospinal pathways are not fully developed
• Cranial Nerves
  
  1. Regards face =
  2. Optic blink - response to light =(2)
  3. Tracks smile or object (3)
  4. Rooting reflex; sucking =
  5. Crying face symmetric =
  6. Tracking or blinking in response to sound =
  7. Assess swallowing, gag reflex (2)
  8. Observe symmetry of shoulders =
  9. Pinch nostril, observe for opening of mouth with tip of tongue midline =

Answer 16

• Pain
• Deep Tendon
• Cranial Nerves
  
  1. CN II
  2. CN II/III
  3. CN III, IV, VI
  4. CN V
  5. CN VII
  6. CN VIII
  7. CN IX, X
  8. CN XI
  9. CN XII

Question 17

Anticipatory Guidance

• Babies cannot be _____
• Need to feel ____
• Are much happier and more predictable when parents respond q____ and effectively
• There are c_____ differences in child rearing, no one way to do things, many ways work
• But need to be responsive to the needs of infants and reflect a c____ and nurturing style of parenting
• Sl___, F____, Childc____, Re_____

Answer 17

• spoiled (cannot self soothe when infant so okay to give them attention)
• secure
• quickly
• cultural
• caring
• Sleep, Feeding, Childcare, Reassurance

Question 18

Feeding

• Breast or Formula
  
  • On ____
  • Every _-_ hrs for the first week or so
  • Then every _-_ hrs
  • __-__min per breast
  • __-__ oz per feeding w formula
  • Often fall ____ during feedings, may need to stimulate them to stay alert
  • Don’t let neonate go more than __ hrs without eating
• Commom complaints
  
  • Falling asleep at breast or bottle -> un____ some, ____ cheeck
  • G____: make sure ____ between breast or btwn every 1-2 oz of formula

Answer 18

• Breast or Formula
  
  • demand
  • 1-2 hrs
  • 2-2.5 hrs
  • 10-15 min
  • 2-3 oz
  • asleep
• Common complaints
  
  • undress, stroke
  • Gassy, burping

Question 19

Sleep

AAP recommendations on creating a safe sleep environment include:

• Place the baby on his or her ___ on a ___ sleep surface such as a crib or bassinet with a ___ fitting sheet
• Avoid use of ____ bedding, including crib bumpers, blankets, pillows, and soft toys. The cribs should be ____
• Share a bedroom with parents, but not the same sleeping surface, preferably until the baby turns 1 but at least for __ months. Room sharing decreases risk of ____ by 50%
• Avoid baby’s exposure to sm___, alc___, illicit ____

Answer 19

• back, firm, tight
• no soft, cribs bare
• share room 6m, decreases SIDS
• no smoke, alc, drugs

Question 20

SIDS

Sudden death of an infant less than __ year that remains ____ after a complete case investigation

• High risk groups
  
  • Low _ _ _ families, gender?
  • Family hx of heavy ____ or drug abuse
  • Infants with low birth ___, bl___
  • Al____ and American ____ ethnicities
  • Subsequent s____ of SIDS victims
  • Pre____ infants with recurrent ap____ episodes

Answer 20

<1 yr, unexplained

• SES
• smoking
• weight, black
• Alaskin, Indian
• Siblings
• Premature, apneic

Question 21

SIDS Interventions

• “____ to sleep” (supine position)
• Crib safety and bedding
  
  • ____ 2 3/8 inches apart, f___ mattress, no pl____
  • Crib alternatives include flat/l___/firm surface, dr____, M____ basket, etc
• Avoid overh_____, maintain room temp 68-72F
• Avoid bed ____/co-sleeping
• Sleep in ____ room
• Avoid al___/dr___. Especially cigarette smoking in hour or car and during breastfeeding

Answer 21

• Back
• Crib safety
  
  • Slats, firm, no plastic
  • low, drawer, Moses
• overheating
• avoid bed sharing
• parents room
• alc/drugs

Question 22

Neonatal Hyperbilirubinemia

Jaundice is a yellow discoloration of the sk___ and e___ by hyper_____ (elevated serum bilirubin concentration)

• The serum bilirubin lvl requires to cause jaundice varies with skin t___ and body r____, but jaundice usually becomes visible on ___ at a lvl of 2-3 mg/dL and on ___ about 4-5 mg/dL
• With increasing bilirubin lvls, jaundice seems to advance in a ___ to ___ direction
• Occurs in greater than __% of all newborns

Answer 22

skin, eyes, hyerbilirubinemia

• tone, region, sclera (2-3), face (4-5)
• head to toe
• 50%

Question 23

Metabolism of Bilirubin

• Unconjugated -Indirect =
• Conjugated - Direct =
• Which one do we want?

Answer 23

• Bound to albumin
• After going through hepatocyte binds to glucoronic acid
• We want conjugated bili - comes out through feces

Question 24

Jaundice

• Neonatal hyperbilirubinemia in infants > __ weeks gestational age (GA) is defined as total serum or plasma bilirubin (TB) > __th percentile on the hour - specific Bhutani nomogram
• High TB can lead to acute bilirubin _______**
• Normal to slightly elevated bili at birth __mg/dL
• Tx = ___therapy

Answer 24

• 35wks, 95th percentile
• encephalopathy
• 1mg/dL
• Photherapy

Question 25

Risk factors for Jaundice ## Footnote Major Risk Factors * Pre\_\_\_\_ TB or TcB level in the high risk zone * Jaundice observed in the first __ hrs * ____ group incompatability with positive direct antiglobin test, other known h\_\_\_\_\_ disase (G6PD deficiency), elevated ETCOc * Gestational age \_\_-\_\_ wks * Previous _____ received phototherapy * Cephalohematoma or significant b\_\_\_\_\_ * Exclusive breastfeeding, particularly if nursing is not going ___ and ___ loss is excessive * East ____ race

Answer 25

* predischarge * 24 * blood, hemolytic * 35-36wks * siblings * bruising * well, weight loss * Asian

Question 26

Hemolytic Anemia ## Footnote * **\_\_\_\_ Incompatibility** * **​**More common and severe in infants of ____ descent * Mothers __ type -\> Baby is either __ or \_ * Increased in pre\_\_\_\_ * F\_\_\_\_ born infants * **\_\_ Factor Incompatibility** * **​**Mother Rh \_\_\_\_ * Infant Rh \_\_\_\_ * Production of _____ that pass thru the placenta at birth * First pregnancy is \_\_\_\_ * Second pregnancy if infant Rh+ can lead to \_\_\_\_\_

Answer 26

* **ABO** * **​**African * O, A or B * premature * First * **Rh** * negative * positive * antibodies * fine * anemia

Question 27

Causes of Jaundice ## Footnote **Unconjugated Hyperbilirubinemia** * **(1):** Resulting from rapid breakdown of RBC and poor clearance in the liver, quick rise then drop * **(1):** Occurs in the first few days of life when breast milk not in or infant not eating enough, may have weight loss, dehydration from lack of nutrition * **(1):** Develops after the 5-7 days of life in breastfed infants peeks at week 2. Felt related to increased concentration of B-glucuronidase in breast milk, causing an increase in the deconjugation and reabsorption of bilirubin.

Answer 27

**Physiologic** **Breastfeeding Jaundice** **Breast Milk Jaundice**

Question 28

Pathologic Hyperbilirubinemia ## Footnote * Diagnosis of pathologic hyperbilirubinemia include * Jaundice appears in the first __ hrs * After ____ wk of life or lasts \> __ wks * Total serum bilirubin (TSB) rises by \> __ mg/dl/day * TSB \> __ mg/dL * Infant shows \_\_/\_\_ of illness * Common causes * Immune and Non-immune hemolytic \_\_\_\_ * G\_\_\_ deficiency * H\_\_\_\_ reabsorption * Se\_\_\_\_ * Hypo\_\_\_\_\_\_

Answer 28

* Diagnosis * 24 * 1 wk, lasts \>2 wks * rises by \>5mg/dL * \>18 mg/dL * S/S * Common causes * anemia * G6PD * Hematoma * Sepsis * Hypothyroidism

Question 29

Jaundice ## Footnote * **Presentation** * **​**Dis\_\_\_\_\_ of the skin * Starts from \_\_\_\_caudal presentaton * **Treatment** * **​**Based on r\_\_\_ f\_\_\_\_ * P\_\_\_therapy * ____ breastfeeding * ____ with formula * S\_\_\_\_ total bilirubin lvls * Consider re-\_\_\_\_ trending upward or in the moderate to high range on graph (for hydration and phototherapy)

Answer 29

* **Presentation** * **​**Discoloration * Cephalocaudal * **Treatment** * **​**risk factors * phototherapy * continue * supplement * Serial * re-admission

Question 30

Acrocyanosis = * Per\_\_\_\_ and Per\_\_\_\_\_ * Common in the first few ____ after delivery in full term and preterm newborns * Usually resolves in \_\_-\_\_ hrs

Answer 30

**Benign, characterized by cyanosis of the hands, feet, and may also occur in face** * Peripheral and Persistent * hours * resolves 24-48 hrs

Question 31

Erythema Toxicum Neonatum = * Onset at 3-14 days of life * Characterized by small 1-3mm wh\_\_\_-y\_\_\_\_ papules, ves\_\_\_ and pus\_\_\_ that are surrounded by a macular er\_\_\_\_\_ base * Baby can have few to several ____ lesions * Lesions are ___ typically found in mucous membranes, palms, and soles * Lesions are _____ and they usually resolve within 3-14 days without permanent sequela

Answer 31

**Benign self limited disorder affecting 30-70% full term newborns (only 5% of premature infants)** * white-yellow, vesicles, pustules, erythematous base * hundred * not found there * transitory

Question 32

Transient Neonatal Pustular Melanosis ## Footnote **Benign, self limited condition with no known sequela** * Overall incidence about 2.2% * More common in ____ infants 4-5% (less than 1% in white babies) * **(3) stages of skin eruption** * On the face, neck and under chin, e\_\_\_\_\_, lower back, shins, p\_\_\_ and s\_\_\_\_ * Differential dx: Neonatal H\_\_\_\_\_

Answer 32

* more common in Black 1. **1-4 mm non-erythematous pustules with milky fluid** 2. **Ruptured vesicopustules with scaling** 3. **Hyperpigmented macules** * extremities, palms, soles * Herpes

Question 33

Slate Gray Nevi = * Diameter maybe \>\_\_ cm * Commonly locate on (2) regions * Begin to fade by first or second ____ of life * By \_\_-\_\_ yrs of age, disappear

Answer 33

**Congenital Blue-grey pigemented macule with indefinite borders (formally named mongolian spot, congenital dermal melanocytosis)** * 10cm * Sacral gluteal region, shoulder * year * 6-10 yrs disappear

Question 34

Cafe-Au Lai Macules = * More than 6 concern for **\_\_\_\_\_\_** * M\_\_\_\_\_ at well exams and monitor for ch\_\_\_\_\_

Answer 34

**Common hyperpigmentation macules of different sizes** * **neurofibromatosis** *(if not related to NF-can fade/go away)* * Measure, changes

Question 35

Hemangioma = * Will ____ first year of life then in\_\_\_\_ * If close to eyes need to refer to \_\_\_ology for treatment

Answer 35

**Usually benign, Vascular Tumor** * grow, involute * dermatology

Question 36

Vascular Lesions ## Footnote What conditions do these pictures show?

Answer 36

**Port Wine Stain- Nevus Flammeus** (may stay forever but can fade) **Salmon Patch/Stork bite-Nevus Simplex** (sometimes called angel kisses when on forehead)

Question 37

Seborrheic Dermatitis- AKA cradle cap = * Can attach to hair \_\_\_\_\_ * Associated with patchy r\_\_ness, small bumps, fissuring, and occassionally w\_\_\_\_\_. * In infants, it is usually not ____ as opposed to children and adults * Usually present in the first __ months. * Is it malignant? * More severe or persistent forms can be \_\_\_\_\_\_ * Consider con\_\_\_\_ treatments first * Removing scales is possible using what? after doing what? * Brush away from the \_\_\_\_\_ * Emollient, such as V\_\_\_\_\_, or appliyng fragrant free oil overnight and then shampoo in the morning

Answer 37

**Scaling, thick, yellow/white, crusty or greasy patches on the scalp, face, between folds of skin and on skin rich in oil glands** * follicles * redness, weeping * not as itchy in infants * 3 mths * Ususally benign and self limiting w resolution within a month * treated * conservative * soft toothbrush or comb after shampooing * away from eyes * Vaseline

Question 38

Neonatal Acne ## Footnote * 20% of infants * **Stimulation of sebaceous ____ by _____ endogenous androgens** * Onset at after __ wks * Inflammatory p\_\_\_\_ and pu\_\_\_\_, no come\_\_\_\_ lesions (like teenagers) * On f\_\_\_ and ch\_\_\_\_ * \_\_\_-limiting

Answer 38

* **sebaceous glands by maternal endogenous androgens** * 2 wks * papules, pustules, no comedome lesions * face, cheeks * self-limiting (will go away by itself, do not squeeze/pop will cause scarring)

Question 39

Milia = * Frequently found on (2) * Resolves when?

Answer 39

**White papules caused by retention of keratin and sebaceous material in pilaceous follicles** * nose and cheeks * resolve in first few weeks of life

Question 40

Prickly Heat ## Footnote (miliaria crystallina or miliaria rubra) **Accumulation of ____ beneath sweat ducts that are obstructed by \_\_\_\_\_** * Occurs with per\_\_\_\_ due to heat * The rash can look like a ____ of tiny bubbles under skin or cluster of small p\_\_\_\_\_

Answer 40

**Accumulation of sweat** **beneath ducts obstructed by keratin** * perspiration * cluster of bubbles under skin, cluster of small pimples

Question 41

Crying ## Footnote * Infants cry \_-\_ hrs/day * They cry because they are? (Identify why and address it) * Usually are ____ to console * Infant self sooth by suckling (offer \_\_\_\_, ____ to suck on can help)

Answer 41

* 1-3 hrs * Hungry, Bored, Wet, Tired, Pain, Teething, Illness * easy * pacifier, pinky

Question 42

Colic ## Footnote **In\_\_\_\_\_ crying in an otherwise healthy infant starting at __ wks and begins to improve at ~ __ months** * 7-40% of full term infants * **Rule of 3's =** * Peaks during what times of the day? * What is the cause? Can be very difficult to parent, may interefere with infant/caregiver b\_\_\_\_\_

Answer 42

**Inconsolable crying, 2wks -\> 3mths** * **3hrs/day, 3days/wk, \>3wks** * late afternoon/early evening * No clear understing of etiology or pathophysiology, interferes w infant/caregiver bonding

Question 43

GI Gastroesophageal Reflux = * Different from vomiting in that vomiting is a _____ expulsion of stomach contents * Common for infants to spit up after \_\_\_\_ * Most common cause is from ingestion of ___ while sucking * Frequent _____ will decrease spitting up * Over _____ causes an increase in reflux

Answer 43

**AKA spitting up- regurgitation** * forceful * eating * air * burping * overfeeding increases reflux

Question 44

**Gastroesophageal Reflux *Disease*** ## Footnote **Term used when presence of ___ loss, dis\_\_\_\_ are present** * Infant will usually pull ___ up when feeding or cry when spitting up * Will initially want to eat more and then will ___ eating as it is associated with discomfort * Initial treatment rx (1) * Consider _____ to GI if weight loss present * May consider _____ to cows milk protein especially if diarrhea present

Answer 44

**weight loss, discomfort** * pull legs up * eat more then avoid eating bc discomfort * Famotidine * referral * intolerance

Question 45

Diarrhea ## Footnote Acute = Chronic = May be infectious or non infectious * History = * Physical Exam = _____ Status

Answer 45

Transient, self limited \> 2 wks duration * Length of illness, Stools...frequency, consistency, **presence of blood,** oral intake (assoc vomiting), asctd symptoms (fever, rash), UO, contacts with other infectious illness * Hydration Status * Moist mucosa, presence of saliva and tears, skin turgor, weight, # of diapers, alertness, temp, HEENT, ABD

Question 46

Diarrhea ## Footnote Etiology = Testing =

Answer 46

Usually viral, if blood present eval for colitis or bacterial infection Usually none unless duration longer than a week, then obtain stool culture and sensitivity along with Ova and Parasites, consider E-coli if risk factors

Question 47

Diarrhea ## Footnote Treatment =

Answer 47

Hydration is Key * Pedialyte, Ricealyte (ORS): 1mL of ORS per kg of body weight every 5 minutes over 3 to 4 hours * Assess for dehydration * Obtain weight and compare to last weight * 6-9%...dry mouth, absence of tears * \>10% sunken eyes, poor turgor, sunken fontanels

Question 48

Symptoms of Severe Dehydration ## Footnote \*Is a medical \_\_\_\_\_\* And should seek immediate medical attention. These children appear ____ (difficult to keep awake) or may be un\_\_\_\_. They also may have: poor ____ or may be unable to drink * A parched mouth and t\_\_\_\_\_ * Minimal or no ____ output * Increased ___ rate, ___ pulses, ___ breathing, cool, m\_\_\_ extremities * Cap refill that is very ____ or minimal * Deeply ____ eyes (and/or fontanel in baby) * Check urine d\_\_\_\_\_

Answer 48

Emergency!\* lethargic, unconscious, poor drinking * parched tongue * no urine * increased HR, weak pulses, deep breathing, mottle extremities * prolonged * sunken * dipstick

Question 49

Diarrhea ## Footnote Follow up = Hospitalize if?

Answer 49

Phone in 12 and 24 hrs, intake, # of diapers, fever, activity, F/U in office 48hrs Unable to keep fluids in, Bloody diarrhea, Lethargy, Concern about parenting, \>10% dehydration (sunken fontanels, poor turgor)

Question 50

Food Protein Enterocolitis ## Footnote * Usually within first few days of life * Will show signs of milk/casein \_\_\_\_\_ * If severe will have vomiting and diarrhea, milder forms may have ____ tinged diarrhea * Can be associated with **\_\_\_\_\_\_**

Answer 50

* few days of life * milk/casein allergy * blood * **eczema** (very macular unlike other conditions more pustular)