Beruflich Dokumente
Kultur Dokumente
months)
User: Larissa Wolf
Email: lwolf4@uthsc.edu
Date: July 09, 2018 02:25 GMT/UTC
Learning Objectives
Recognize appropriate growth patterns in infants up to 9 months of age using standard growth charts.
Summarize nutritional requirements for appropriate growth for infants at ages 2, 6, and 9 months, including
caloric requirements, differences between formula and breast milk, and how and when to add solid foods to the
diet.
Explain the difference between developmental surveillance and developmental screening.
List normal developmental milestones at 2, 4 and 6 months.
Discuss the importance of prevention and anticipatory guidance during the well visits, including behavior,
development, safety and immunizations.
Develop a differential diagnosis for an asymptomatic abdominal mass in an infant; formulate a plan for
evaluation.
Knowledge
Interval History
Ask if there have been any illnesses or problems since the previous visit.
If this is the first visit, obtain a detailed birth history.
Using the available medical records, review any visit notes, hospitalizations, lab results, and radiology
reports since the last visit.
Development
May be assessed using one of several developmental screening tests (e.g., the Parents' Evaluation of
Developmental Status [PEDS], or Ages and Stages Questionnaire [ASQ]).
The American Academy of Pediatrics (AAP) recommends developmental screening with a validated tool at
the 9-month, 18-month, and 30-month checkups.
Specific autism screening is recommended at the 18-month and 24-month visits.
Developmental surveillance is recommended at every health maintenance visit where a validated
developmental screening tool is not used.
Tests may involve parental reports and/or examination in the office.
Growth
Growth is best assessed using a growth chart and analyzing the data over time.
Diet History
Inquire about feeding practices: breast or bottle (in infants), or types and frequency of food and drink (in
older children), and any feeding difficulties the parent has noted.
Family History
A family health history should be obtained at the initial visit and updated yearly.
Social History
Ask who lives in the household, who the primary caretakers are, and who takes care of the child when the
parents are at work or school.
Also assess for environmental risks (e.g., smokers, guns in the home, lead exposure).
Physical Exam
Anticipatory Guidance
Each visit includes anticipatory guidance, which is your chance to help the parents anticipate the child's
development and nutritional needs and to advise them regarding the child's safety.
Age-specific recommended immunizations and screening labs are performed at the conclusion of the visit.
Nutrition Guidance
Breast Milk
Formula
Commercial formulas provide complete nutrition for those babies whose mothers are unable or unwilling to
breastfeed. Available formulas include those made with:
There are also specialized formulas that provide protein in the form of simple amino acids (the true elemental
formulas).
There is no need to give an infant extra bottles containing water only, because formula or breast milk fulfills
maintenance fluid requirements.
Infants should take breast milk or formula until 12 months of age. According to the American Academy of
Pediatrics:
Young infants cannot digest cow's milk as completely or easily as they digest breast milk or formula.
Cow's milk contains high concentrations of protein and minerals, which can stress a newborn's immature
kidneys.
Cow's milk lacks iron, vitamin C, and other nutrients that infants need.
Cow's milk can irritate the lining of the stomach and intestine, leading to blood loss in the stool.
Cow's milk does not contain the optimal types of fat for growing infants.
Early Growth
Infants born at >37 weeks gestational age require 100 to 120 cal/kg/day. Average daily weight gain
Term infants
for term infants is 20 to 30 grams.
Preterm
Infants born at < 37 weeks gestational age require 115 to 130 cal/kg/day.
infants
Very preterm
Infants born at < 32 weeks gestational age require up to 150 cal/kg/day.
infants
Moro Reflex
This reflex is elicited by an abrupt change in the infant's head position and consists of two parts:
Symmetric abduction
Extension of the arms followed by adduction of the arms, sometimes with a cry.
The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or
neural plexus injuries.
Evaluating a child's development may take place routinely during the well-child visit and at any other patient
encounter if the examiner or parent has concerns, even during an acute visit or hospitalization.
Developmental Surveillance
Checking milestones (comparing a child's behaviors to expected behaviors by age) is known as developmental
surveillance.
Gross motor
Fine motor
Communication/social
Cognitive/adaptive
If the child is not capable of passing the milestones in any of the four areas at or near the appropriate age, then
these areas are of concern for possible delay and should be followed up or further testing or evaluation should be
done.
Developmental Screening
Surveillance is not as sensitive or specific as using a validated developmental screening test to pick up true
developmental or behavioral abnormalities.
For more information on developmental screening, see the AAP's Policy Statement and Aquifer's tool for learning
the milestones, which includes videos demonstrating expected milestones in all four domains at each
recommended well-visit age (2 months, 4 months, 6 months) from birth to age 5.
Solid Foods
Babies are developmentally ready to begin spoon feeding solid foods between 4 and 6 months of age.
Vitamin D
The recommended allowance of vitamin D for children up to 12 months of age is 400 units per day.
While there is remarkable evidence on the nutritional superiority of breast milk, there has been a concern
that the amount of vitamin D in breast milk is not adequate. Unless infants drink 32 ounces (one quart) of
formula or milk a day (both of which are supplemented with vitamin D), they may not receive enough vitamin
D.
All breastfeeding infants and all infants drinking less than a quart per day of formula should receive vitamin
D supplementation.
Infants who are breastfeeding should begin supplementation with liquid vitamin drops in the first few days of
life.
More information on vitamin D: AAP Policy Statement on Prevention of Rickets and Vitamin D Deficiency in
Infants, Children, and Adolescents.
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related
infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics.
2016;138(5):e20162938
American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related
infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics.
2016;138(5):e20162938. Accessed March 15, 2018.
Child Care
Sleep
Safety
Family members who smoke should be advised to quit or, at the very least, should avoid smoking around
the infant.
Small objects and plastic bags should be kept away from the baby to avoid choking and suffocation.
Do not drink hot liquids while holding the baby.
Do not leave the infant alone on high places like the sofa or changing table. Always keep a hand on these
squiggly babies!
Children under age 13 years old should not sit in the front seat.
Until age 2 years, children should face rearward.
The National Safety Transportation Board and the AAP stress that the back seat is the safest place in a
vehicle for children.
The middle of the back is the most protected part of the automobile.
Car seats for children are required by law in all 50 states. Proper use is essential for optimum performance.
The most effective car seat restraint is a five-point harness, consisting of two shoulder straps, a lap belt and
Immunizations in Childhood
These are the vaccines and the number of doses of each that children should receive through 6 years of age:
IPV Polio 4
Varicella Varicella 2
HepA Hepatitis A 2
HepB Hepatitis B 3
Seasonal Influenza
Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have
contraindications.
Combination Vaccines
Combination vaccines represent one solution to the issue of increased numbers of injections during single clinic
visits, and may be used instead of their equivalent component vaccines if licensed and indicated for the patient's
age. Examples of combination vaccines are Pediarix® (DTaP, Hep B, IPV) and Pentacel® (DTaP, IPV, Hib).
Common side effects of immunizations include redness or swelling at the injection site, fussiness, and low-grade
fever. Significant health problems that occur after immunization should be evaluated immediately and reported to
the CDC's national vaccine safety surveillance program, VAERS. The risks of adverse effects are far outweighed
by the risks of serious consequences from contracting the diseases themselves, so the AAP recommends routine
immunization of all healthy children.
Most healthy infants will double their birth weight by 4 to 5 months and will triple their birth weight by 1 year of age.
In addition, most children will reach double their birth length by age 4 years.
Former preemies, small for gestational age babies, and others with chronic health issues do not always follow this
pattern, and there are separate growth charts available for these special populations.
© 2018 Aquifer 5/11
In 2006, the World Health Organization (WHO) released a new international growth standard which reflects how
infants and young children grow under optimal nutritional conditions. The WHO standards establish the growth of
the breastfed infant as the norm and provide a better description of ideal, rather than typical, growth patterns.
WHO Growth Standards Are Recommended for Use in the U.S. for Infants and Children 0 to 2 Years of Age.
Description
The red reflex is the red or orange color reflected from the fundus through the pupil when viewed through an
ophthalmoscope approximately 10 inches from the patient. It gives direct information about the clarity of the eye
structures and therefore is a substitute for a careful fundoscopic exam, since a 6-month-old will not hold his or her
gaze long enough for the examiner to visualize the retina consistently. Examination of the red reflex should be
performed in a darkened room. In infants with more darkly pigmented skin the reflex may appear more gray than
red.
This reflex should be elicited in all infants and children, beginning at birth.
Absence of a symmetric red reflex or the presence of leukocoria (white pupil) may indicate underlying
abnormalities, including:
Cataracts
Glaucoma
Retinoblastoma
Chorioretinitis
When to Refer
A pediatric ophthalmologist should be consulted immediately if leukocoria, an abnormal or asymmetric red reflex,
or signs of nonaccidental trauma are identified on physical examination.
Rolls over
Language Babbles (i.e., use of repetitive consonants: ba-ba-ba or da-da-da) (When the child says da-
da-da, the family reinforces the sounds by praising the infant; then the infant makes the
connection of the sound to the father.)
Feeds self
Social/Adaptive
Demonstrates stranger recognition, the prelude to stranger anxiety
There are several steps parents or guardians should take to childproof their home - before children begin crawling
In addition, the number for poison control should be kept near the phone.
Car seat placement: The car seat should still be in the back seat, facing the rear.
Use of walkers: The AAP has recommended against the use of walkers because of the risk of injury, especially
when there are stairs in the home. In addition, walkers do not teach children to walk any earlier than they
otherwise would.
Dietary changes:
Developmental changes:
6-month-olds may be resistant to being away from their primary caretaker for the next few months, but this
"stranger anxiety" is normal.
If not already begun, now is a great time to start reading books to the infant.
The 6-month-old should be expected to take two naps per day, and will probably sleep through the night.
The AAP's website HealthyChildren.org has much more information on anticipatory guidance and well-child care
for parents and professionals.
Members of the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and American
Academy of Family Physicians meet annually to formulate an immunizations schedule that is as evidence-based as
is possible. The current year's immunization requirements are available from the CDC .
The use of antipyretics for the prevention of fevers associated with vaccine administration merits careful
consideration. The prophylactic administration of acetaminophen has been associated with decreased antibody
concentrations for some vaccine antigens, although all concentrations remained in the protective range.
This is due to the unique nature of this tumor derived from embryonal cell lines.
Genetics of Neuroblastoma
Familial
According to the most recent studies, there are familial forms of neuroblastoma, but these account for only about
1% of cases. The familial form appears to be autosomal dominant, with low penetrance.
Penetrance refers to the percent of individuals with a mutation that display the clinical effects of the
mutation.
The fact that the mutation causing familial neuroblastoma has low penetrance means that many people who
inherit the mutation will not have neuroblastoma.
For patients with a family history of neuroblastoma, genetic tests to determine if germline mutations in the
PHOX2B or ALK genes are commonly done.
These pedigrees show examples of the autosomal dominant inheritance with complete and low penetrance:
Examples of the autosomal dominant inheritance with complete and low penetrance
Non-Familial
Most cases of neuroblastoma are due to somatic mutations. That is, these mutations arise in cells other than the
gametes. Somatic mutations are not passed to the next generation.
Clinical Skills
Growth Parameters
Review the weight and length as recorded, repeating any measurement that is concerning or seems
inconsistent.
Head Circumference
Measure the circumference around the widest portion of the head, from the broadest part of the forehead to
the occipital prominence at the back of the head.
Growth Chart
There are a number of acceptable ways to introduce a difficult topic such as a serious diagnosis to the family. Of
course, as the family begins to understand the enormity of the diagnosis, they may not be ready to receive any
more information.
Some recommendations:
Delivering information in a direct but caring fashion can allow a family member to start processing bad
news.
Expect family members to react emotionally, and be prepared to respect and support their feelings.
When the family is emotionally ready to hear more information, it is important to convey that treatment
decisions need to be made urgently.
Studies
Initial Testing
The CBC with differential is helpful in identifying the extent of anemia and to look for cytopenia that may be
associated with bone marrow infiltration.
This test is not specific for any one diagnosis.
Urine or serum VMA/HVA measures metabolites of catecholamines, which are elevated in neuroblastoma.
This test is highly specific for neuroblastoma and can be 90-95% sensitive in its detection.
Chest x-ray
Skeletal Survey
Abdominal Ultrasound
An abdominal ultrasound will identify a mass, show the organ of origin, and determine if the mass is solid,
cystic or combined. (Purely cystic masses are less likely to be malignant.)
This is the best choice for a first imaging study.
Abdominal x-ray
A plain film can identify the presence of a mass, and perhaps whether it has calcifications, it cannot reveal
other important information about the mass.
This film may be more urgent if there is any evidence of bowel obstruction from the mass.
The plain radiograph is not the best imaging study to order first.
Abdominal CT
A CT is best at revealing calcifications, and-importantly especially for a surgeon-shows the anatomy better
than an ultrasound. It also reveals the consistency of the tumor.
Allows evaluation of the lungs during the same study, which is important in finding metastases.
If a lesion is purely cystic, a CT scan is not needed, which is why an ultrasound is done first.
Clinical Reasoning
© 2018 Aquifer 9/11
Clinical Reasoning
Serious illnesses may cause a decrease in growth and even weight loss, but normal growth should not eliminate
serious diagnoses from your differential.
Condition Discussion
Although rare in children this age, an hepatic neoplasm (whether malignant, such as
Hepatic hepatoblastoma, or benign) can cause an asymptomatic abdominal tumor and must be
neoplasm considered in a young infant with an asymptomatic RUQ abdominal mass.
Jaundice may be a feature, but the lack of jaundice does not rule out this diagnosis.
The most frequently diagnosed neoplasm in infants; more than half of patients present
before age 2.
The tumor may present as a painless mass in the neck, chest, or abdomen.
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.
This is a likely diagnosis in a child with an asymptomatic RUQ abdominal mass who
has no lymphadenopathy or jaundice on exam and who is growing and developing
normally.
Associated symptoms occur in 50% of patients and include abdominal pain and/or
vomiting; patients may also be hypertensive.
Bickley LS, Hoekelman RA. Bates' Guide to Physical Examination and History Taking . 7th edition, Philadelphia:
Lippincott; 1999.
Zitelli BJ, Davis HW. Atlas of Pediatric Physical Diagnosis . 4th ed., St. Louis, MO: C.V. Mosby; 2002:58.
2009 Glascoe FP, Roberstshaw NS, Ellsworth & Vandermeer Press, LLC, 1013 Austin Court, Nolensville, TN 37135.
http://www.pedstest.com.
Identifying Infants and Young Children With Developmental Disorders in the Medical Home: An Algorithm for
Developmental Surveillance and Screening. Pediatrics. 2006;118(1). Policy statement reaffirmed by the AAP
November 2014 http://pediatrics.aappublications.org/content/118/1/405.full.
Wagner, CL, Greer, FR, and the section on Breastfeeding and Committee on Nutrition. Prevention of rickets and
vitamin D deficiency in infants, children, and adolescents: American Academy of Pediatrics Clinical Report. Pediatrics
2008;122(5); 1142-1152. http://pediatrics.aappublications.org/content/122/5/1142.full.
Resources
Link to the CDC's webpage for current immunization schedules for children and adolescents.
Bickley LS, Hoekelman RA. Bates' Guide to Physical Examination and History Taking . 7th ed., Philadelphia: Lippincott;
1999.
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, Third Edition (2008), an AAP
publication.
Shelov S, ed. Caring for Your Baby and Young Child: Birth to Age 5 . American Academy of Pediatrics. New York:
Bantam; 1998.
Bickley LS, Hoekelman RA. Bates' Guide to Physical Examination and History Taking . 7th ed., Philadelphia: Lippincott;
1999:687-688.
Shojaei-Brosseau T, Chompret A, Abel A, de Vathaire F, Raquin MA, Brugieres L, Feunteun J, Hartmann O, Bonaiti-
Pellie C. Genetic epidemiology of neuroblastoma: a study of 426 cases at the Institut Gustave-Roussy in France.
Pediatr Blood Cancer. 2004 Jan;42(1):99-105.