Lecture 5 Flashcards
(37 cards)
how is growth in a child measured
o Weight, length, head circumference and weight/length are measured at each visit.
o These are plotted on validated growth charts to track appropriate growth.
o Both the CDC and WHO offer growth charts for typically developing children.
o Most children will follow one line, however slight deviation can occur. Jumps of more than 2 lines can indicate pathology.
o Other growth charts exist for children with conditions such as Down’s Syndrome and Turner’s Syndrome.
o A child does not have to follow the same percentile for all of their growth parameters.
o The pattern in which children deviate from their growth curve can indicate the pathology. Ex. Calorie deficiency would first show a drop in weight, then height and then head circumference.
o Head growth is conserved above all else.
o HEAD GROWTH IS REALLY A PROXY OF THE BRAIN GROWTH! Good predictor of cognitive outcome
o A normal child will lose around 8% of the body weight at first
o 30 grams
normal patterns in growth
o Normal infants may have up to a 10% drop in weight following birth. This should be regained by 10 days of life.
If they have lost more than 10% of the birth weight, this is very worrisome for dehydration, etc.
o For the first 4 months, infants will gain about 30 grams per day (an ounce).
o Infants who started out in a high growth percentile may settle out at a lower one and those who were initially small will generally catch up.
development
o Development and behavioral problems are the most common issues in pediatrics following infection and trauma.
o “Surveillance” should be done at every well child visit.
o If surveillance questions demonstrate a risk for delay then a screening test should be administered. Screening Tools on AAP Website
o It is important to find children with developmental delay early because early intervention has the best results.
o Nelson’s pediatric essentials – has tables of the milestones of development that we should know
o Ages and Stages Questionnaire (ASQ)- most popular in this area.
o Filled out by parent – get a copy of it at most WCC visit
Don’t need to memorize the questions, just know general idea of what is asked
o Assesses: gross motor, fine motor, communication, problem solving and personal-social
o Traditionally done at 9 month, 18 months and 30 months. Can be practice specific.
o Children develop at different rates. Just because they do not meet their milestone perfectly does not mean there is a significant delay. However, there is little harm in referring for further evaluation if delay is suspected.
o Speech is the parameter that is most closely tied with proper cognitive development.
o Any deficits in speech should trigger a hearing assessment even if they passed their birth hearing screen.
development assessment and screening
o Assessment tools generally look at:
Gross Motor: head control, sitting, walking
Fine Motor: Follow past midline, pincer grasp, reaching, scribbling
Personal-Social: eye contact, social smile, mimicking expressions
Cognitive:
• Language: cooing, babbling, speaking
• Problem Solving: If a baby sees you hide a toy will they look for it.
autism
Screening for autism occurs between 18-24 months.
Modified Checklist for Autism (M-CHAT) is the gold standard screening tool
It looks at 23 typical behaviors
Some are more predictive than others.
If the child displays 2 predictive or 3 total behaviors then further assessment is indicated.
Well child check
o The patient should be well during this visit.
o The patient should be accompanied by their main caregiver.
o Schedule: 2 days, 1 week, 2 weeks, 1 mo (variability) 2 mo 4 mo 6 mo 9 mo 1 yr 15 mo 18 mo 24 mo 2.5 yr 3 yr 4 yr
why do a WCC so frequently?
o Children do a lot of growing!
Early interventions can make a really significant difference!
o Each visit is designed to monitor growth and development so that any child that is showing signs of poor development can be referred for special treatment.
o Outcomes are best when interventions are done early.
o Visits also align with CDC vaccine schedule.
birth to 2 mo
o Infants are seen at 2 days, 1week, and then 2 weeks-1 month
o Purpose of these visits are to ensure proper weight gain and offer support to mom.
o Provider should try to talk to mom alone for at least part of the visits to assess her mental and emotional state.
o Infants should be started on a multivitamin.
developmental milestones
o Newborn- 2 weeks
social – regards face, social smile
fine motor - grasp reflex, tracks past midline
language - vocalizes (cries, coos), alerts to bell
gross motor - moves head side to side, lifts shoulders when prone
safety - baths
o sponge baths until 1-2 days after umbilical stump falls off
o newborns do not need regular bathing, only “as needed”
o once mobile, infants get much dirtier
o never unattended
o sink is OK up to one month
baby can turn on the water by accident
colic
o Crying- Normal phenomenon of newborn. Increases during 2 week to 9 week time period. Peaks at 6 weeks.
o Colic: <3 months with at least 3 hours of crying at least 3 days a week. Dx of exclusion
o Anticipatory Guidance
Maternal Depression
Coping Skills
o Review and Reassurance
Awareness of parental time-out
pediatric breathing
o newborns pause normally during breathing
o occurs both during feeding and when not feeding
o Apnea
>20 seconds without discernible air exchange
can be accompanied by cyanosis
distinguish perioral vs. labial/lingual cyanosis
all cyanosis is serious regardless of whether apnea is concurrent
RR 60 is a pretty normal rate for newborns
circumcision
o AAP: Personal decision of the family. It has been shown to be beneficial in preventing UTI and HIV transmission in sexually active individuals.
o Procedure is safest and least expensive if done within the first month of life.
o Often not covered by insurance and parents will need to pay out of pocket.
o Patients with hypospadius and other congenital malformations are not candidates for simple circumcision because foreskin is needed for repair.
SIDS
o Sudden infant death syndrome
the sudden death of an infant or young child, which is unexplained by history and in which a thorough postmortem evaluation fails to demonstrate an adequate cause of death
o Rate of SIDS has declined by over 50% since 1992
Decline correlates with back to sleep campaign, decrease in smoking, better pre-natal care
Sleep => Supine (not prone)
o peak incidence between 1 to 4 months
risk factors for SIDS
o male gender o low birth weight o lower socioeconomic status o maternal smoking o seasonal distribution/winter o young maternal age o high parity o single parenthood o multiple gestation o prematurity
o unsafe sleep conditions soft bedding waterbeds sheepskins soft mattresses Cosleeping is a big factor in SIDS!
advice to prevent SIDS
o Sleep Supine “Back to Sleep” o No Wedges, No Side Sleeping o Bedding needs to be firm o No Soft bumpers, Extra Pillows o No Overheating o No Co-Sleeping o Eliminate Tobacco, Drug, Alcohol use o Consider Pacifier use
BRUE and ALTE
o BRUE= Brief Resolved Unexplained Event
o A brief event that was witnessed by a caregiver that was alarming and has since resolved. Event could be cyanosis, breathing irregularity, changes in tone or changes in level of consciousness.
o ALTE= Apparent Life Threatening Event is old terminology, but is still used and can refer to a longer more concerning event.
BRUE
o Features of lower risk BRUE
Age >60 days
Gestational age ≥32 wks and postconceptional age ≥ 45 weeks
First time BRUE
Duration < 1 min
No CPR from trained provider.
No concerning history or physical exam findings
o Often times related to feeding difficulties or upper respiratory symptoms.
o Management:
If consistent with low-risk BRUE can educate parents on features of BRUE, train in CPR, shared decision making on dispo with parents, follow up with PMD in 24 hours.
• Can consider EKG, brief observation in hospital and pertussis testing
If history or exam shows concerning features ( ex. Story is concerning for seizure, exam shows significant bruising or signs of trauma) then further evaluation is warranted.
4 mo WCC
o Milestones
o Reflexes
o Start sleeping through the night and introducing table foods
developmental milestones at 4 months
o 4 months
social – looks at hand, copies facial expressions, happy
fine motor – reaches for object
language - laughs, squeals
gross motor- chest-up with arm support, holds head steady, no head lag; works for toy, rolls front to back
o SIDS rate decreases because they can support their upper body when lying on their stomach
when do normal primitive reflexes disappear
Moro – disappears by 4 to 6 months
rooting – disappears by 4 to 6 months
sucking – replaced by voluntary sucking
grasp reflex – disappears by 3 to 4 months (plantar 6-15 months)
asymmetric tonic neck reflex – disappears by 2 to 3 months
sleeping at 4 months
o At around 4 month babies will start to sleep through the night.
o This is where sleep can become a big issue.
o Babies should be put down in their crib when they are drowsy but not yet asleep so that they can learn to fall asleep by themselves.
o This is not easy and can be very difficult for families.
feeding at 4 months
o Parents can start introducing table foods around 4-6 months of age.
o Babies should display good head control.
o Physically able to take and swallow food.
o They should show interest.
o Can start with any soft/pureed food. Foods should be introduced one at a time.
o Mainly for taste at this time not nutrition.
o No honey until 1 yo.
dacryostenosis
o The most common cause for chronic tearing in newborns.
o Caused by congenital narrowing of the tear duct that prevent proper tear drainage.
o Patients present with chronic tearing, debris in the eye lashes.
o Conjunctiva are generally clear and the patient should not be in discomfort.
o Should clear up by 6 mo of age.
You can massage the eye/nose with warm, clean washcloth to help
o If persists after 6 mo or symptoms seem more concerning (swelling, skin discoloration, signs of infection) then refer to opthalmology.
