Fluent Essays

Week 2 Discussion For this assignment, you will review the latest evidence-based guidelines in the links provided below. Please make sure you are using scholarly references and they should not be older than 5 years. The posts/references must be in APA format.   Apply the information from the Aquifer Case Study to answer the following questions: Discuss the history that you would take on this child in preparation for the well-child visit. Include questions regarding her growth and development that are appropriate for her age. Describe the developmental tool to be used for Asia, its reliability and validity and how Asia scored developmentally on this tool. Is she developmentally appropriate for her age? What immunizations will Asia be given at this visit; what is the patient education and follow-up? Pediatrics 02: Infant female well-child visits (2, 6, and 9 months) User: Elizabeth Hernandez Email: [email protected] Date: August 20, 2021 1:26AM Learning Objectives Interpret standard growth charts to determine appropriate growth patterns in infants 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 Compare and contrast developmental surveillance and developmental screening at well child visits Distinguish normal developmental milestones at 2, 4, 6, 9 and 12 months of age Integrate anticipatory guidance and parental education on topics such as behavior, development, nutrition, safety and immunizations during well child visits Create a differential diagnosis for asymptomatic abdominal mass in a child Propose a workup for an infant with an abdominal mass List the components of a pediatrics health care maintenance office visit. Describe expected weight changes in healthy infants in the first two weeks of life. Describe how to properly obtain and record measurements of growth. Explain how to elicit the Moro reflex and its value in the neurologic assessment of infants. Describe common facial rashes of early infancy. List normal primitive reflexes of infancy. List conditions associated with abnormal red reflex in infants. List normal developmental milestone at 9 and 12 months of age. Knowledge Components of a Well-Child Visit Interval history If this is the first visit, obtain a detailed birth history. Ask if there have been any illnesses or problems since the previous visit. Using the available medical records, review any visit notes, hospitalizations, lab results, and radiology reports since the last visit. Ask about persistence or resolution of any previously identified medical issues. Ask if there are any new concerns today. Development Developmental surveillance is recommended at every well-child visit when a validated developmental screening tool is not used. Developmental surveillance may include eliciting parental concerns about development, reviewing a developmental history if available, direct observation of the child and identification of risk factors for developmental delays. The American Academy of Pediatrics (AAP) recommends developmental screening with a validated tool at the 9-month, 18- month, and 30-month visits. One of several validated developmental screening tools may be used (e.g., the Parents Evaluation of Developmental Status [PEDS], or Ages and Stages Questionnaire [ASQ]. Specific screening for autism spectrum disorder is recommended at the 18-month and 24-month visits. Growth Growth is best assessed using a standard growth chart and analyzing the growth trends for weight, height, and head circumference (in younger children) over time. Diet history Inquire about feeding practices: breastmilk or formula feeding (in infants), or types and frequency of solid 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. Obtaining a family health history is an important component of the well-child visit that can provide information on genetic, behavioral, and environmental risk factors. 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 safety risks (e.g., smokers, guns in the home, lead exposure). © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 1/12 Mothers should be screened for postpartum depression during infant well-child visits at the 1-month , 2-month , 4-month, and 6-month visits, as it can adversely affect the critical period of infant brain development. Physical exam Anticipatory guidance Each visit includes anticipatory guidance, which is your chance to help the parents anticipate the childs development and nutritional needs and to advise them regarding the childs safety. Immunizations and lab work Age-specific recommended immunizations and screening labs are performed at the conclusion of the visit. Nutrition Guidance Breast milk Breast milk is the preferred source of nutrition for most babies. Babies who are exclusively or partially breastfed should receive 400 international units of supplemental vitamin D daily beginning soon after birth. Formula-fed babies consuming less than 1 L of formula per day also need vitamin D supplementation. The American Academy of Pediatrics recommends exclusive breastfeeding until 6 months of age, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare. Formula Commercial formulas provide complete nutrition for those babies whose mothers are unable to or choose not to breastfeed. Available formulas include those made with any of: Cows milk protein Soy protein Hydrolyzed cows milk protein There are also specialized formulas that provide protein in the form of simple amino acids (the true elemental formulas). Preparing the formula Ready-to-feed formula: As the name implies, the formula is ready to feed as is. Powder: For most formulas, the ratio is 2 oz water added for each scoop of powder. Formula concentrate: The ratio is one part concentrate to one part water. There is no need to give an infant extra bottles containing water only, because formula or breast milk fulfills maintenance fluid requirements. Transition to regular cows milk Infants should take breast milk or formula until 12 months of age. According to the American Academy of Pediatrics: Young infants cannot digest cows milk as completely or easily as they digest breast milk or formula. Cows milk contains high concentrations of protein and minerals, which can stress a newborns immature kidneys. Cows milk lacks iron, vitamin C, and other nutrients that infants need. Cows milk can irritate the lining of the stomach and intestine, leading to blood loss in the stool. Cows milk does not contain the optimal types of fat for growing infants. Early Growth Most babies lose some weight in the first days after birth, then may regain their birth weight as early as 1 week of age, but are usually expected to have regained their birth weight by 2 weeks of age. Caloric Requirements of 1- to 2-Month-Olds Term infants Infants born at > 37 weeks gestational age require 100 to 120 kcal/kg/day. Average daily weight gain for terminfants is 20 to 30 grams. Preterm infants Infants born at < 37 weeks gestational age require 115 to 130 kcal/kg/day. Very preterm infants Infants born at < 32 weeks gestational age require up to 150 kcal/kg/day. The Red Reflex Description © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 2/12 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. Moro Reflex This reflex is elicited by an abrupt change in the infants head position and consists of two parts: Symmetric abduction Extension of the arms followed by adduction of the arms, sometimes with a cry The reflex is present at birth and disappears by age 4 months. The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries. Infant Rashes Neonatal acne and seborrheic dermatitis are two common rashes seen at this age. Both are benign and generally resolve over time. Neonatal acne: More accurately referred to as neonatal cephalic pustulosis, it is not true acne but an inflammatory reaction most likely due to colonization with malassezia species of yeast. Inflammatory papules and pustules usually limited to the face and sometimes scalp are common. Photo of neonatal acne. Seborrheic dermatitis: Most commonly presents as yellowish, greasy scales over the scalp, often called cradle cap. But it can also present as erythematous plaques around ears, eyebrows, nasolabial folds, and skin folds of the neck, axillae, and diaper area. Photo of seborrheic dermatitis. Primitive reflexes Primitive reflexes can be used: To evaluate the integrity of the central nervous system To detect developmental delay To assess normal development Abnormalities seen may include asymmetry, absence of appearance—or delay in disappearance—of reflexes. Primitive reflexes present at birth (in addition to the Moro) include: Moro Reflex This reflex is elicited by an abrupt change in the infants head position and consists of two parts: Symmetric abduction Extension of the arms followed by adduction of the arms, sometimes with a cry. The reflex is present at birth and disappears by age 4 months. The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries. Palmar Grasp Infant grasps examiners finger placed in open palm and tightens grasp when finger withdrawn. This reflex must disappear before the infant can begin grasping objects voluntarily. This reflex persists until 2-3 months of age. Plantar Grasp Infant flexes toes downward when examiner presses on ball of foot. This reflex must disappear before the child begins to take steps. Asymmetric Tonic Neck Reflex (Fencing Reflex) When examiner turns head to one side, infant while supine assumes “fencing posture” extending the arm on the same side as the head is turned and bending the other arm at the elbow. This reflex is one of the first steps in hand/eye coordination and must disappear before the infant can reach for objects in or across the midline. Babinski Response © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 3/12 http://www.dermnet.com/images/Acne-Infantile http://www.nizoralshop.com/img/cms/Seborrheic-Dermatitis-in-baby-yellowish-crust.jpg Infant dorsiflexes the big toe and fans the other toes when examiner strokes the lateral aspect of the foots plantar surface. This reflex is normal in children up to 2 years of age. Developmental Surveillance and Screening Evaluating a childs development should always 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 childs behaviors to expected behaviors by age) is known as developmental surveillance. Developmental surveillance generally includes assessment of milestones in four domains. 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. Screening with a validated tool is recommended at 9, 18, and 30 months of age. Specific screening for autism spectrum disorder with a validated tool is recommended at 18 and 24 months of age because these are critical periods of early social and language development. For more information on developmental screening, see the AAPs Policy Statement and Aquifers 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. Anticipatory Guidance at the 2-month Visit Solid Foods Babies are developmentally ready to begin spoon feeding pureed 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 international 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 milk each day (which is 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. Child Care Many parents appreciate receiving materials on choosing a child care center. Sleep Most babies sleep through the night by age 4 to 6 months. To help prevent sudden infant death syndrome, the AAP recommends that, for the first year of life, babies should sleep on their backs in their cribs on a firm surface, without soft objects like bumper pads, comforters, or stuffed animals, ideally, in their parents room. More information on safe sleep: AAP Updated 2016 Recommendations for a Safe Infant Sleeping Environment 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! Car Seat Safety Children under age 13 years old should not sit in the front seat. Until at least age 2 years, children should face rearward and ideally as long as possible until they outgrow their rear facing carseat. The National Safety Transportation Board and the AAP stress that the back seat is the safest place in a vehicle for children. © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 4/12 http://pediatrics.aappublications.org/content/118/1/405.full file:///documents/803 http://pediatrics.aappublications.org/content/122/5/1142.full https://www.healthychildren.org/English/family-life/work-play/Pages/Choosing-a-Childcare-Center.aspx http://pediatrics.aappublications.org/content/138/5/e20162938 The middle of the back seat 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 a crotch strap. Immunizations in Childhood These are the vaccines and the number of doses of each that children should receive through 6 years of age: Disease Vaccine Diseasespread by Disease symptoms Disease complications Chickenpox Varicella vaccine protects against chickenpox. Air, direct contact Rash, tiredness, headache, fever Infected blisters, bleeding disorders, encephalitis (brain swelling), pneumonia (infection in the lungs) Diphtheria DTaP vaccine protects against diphtheria. Air, direct contact Sore throat, mild fever, weakness, swollen glands in neck Swelling of the heart muscle, heart failure, coma, paralysis, death Hib Hib vaccine prote4cts against Haemophilus influenzae type B Air, direct contact May be no symptoms unless bacteria enter the blood Meningitis (infection of the covering around the brain and spinal cord), intellectual disability, epiglottitis (life- threatening infection that can block the windpipe and lead to a serious breathing problems), pneumonia (infection in the lungs), death Hepatitis A HapA vaccine protects against hepatitis A. Direct contact, contaminated food or water May be no symptoms, fever, stomach pain, loss of appetite, fatigue, vomiting, jaundice (yellowing of skin and eyes), dark urine Liver failure, arthralgia (joint pain), kidney, pancreatic and blood disorders Hepatitis B HepB vaccine protects against hepatitis B. Contact with blood for body fluids May be no symptoms, fever, headache, weakness, vomiting, jaundice (yellowing of skin and eyes), joint pain Chronic liver infection, liver failure, liver cancer Influenza (Flu) Flu vaccine protects against influenza Air, direct contact Fever, muscle pain, sore throat, cough, extreme fatigue Pneumonia (infection in the lungs) Measles MMR** vaccine protects against measles. Air, direct contact Rash, fever, cough, runny nose, pink eye Encephalitis (brain swelling), pneumonia (infection in the lungs), death Mumps MMR**vaccine protects against mumps. Air, direct contact Swollen salivary glands (under the jaw), fever, headache, tiredness, muscle pain Meningitis (infection of the covering around the brain and spinal cord), encephalitis (brain swelling), inflammation of testicles or ovaries, deafness Pertussis DTaP* vaccine protects against pertussis (whooping cough). Air, direct contact Sever cough, runny nose, apnea (a pause in breathing in infants) Pneumonia (infection in the lungs), death Polio IPV vaccine protects against polio. Air, direct contact, through the mouth May be no symptoms, sore throat, fever, nausea, headache Paralysis, death © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 5/12 Pneumococcal PCV13 vaccine protects against pheumococcus Air, direct contact May be no symptoms, pneumonia (infection in the lungs) Bacteremia (blood infections), meningitis (infection of the covering around the brain and spinal cord), death Rotavirus RV vaccine protects against rotavirus. Through the mouth Diarrhea, fever, vomiting Sever diarrhea, dehydration Rubella MMR** vaccine protects against rubella. Air, direct contact Sometimes rash, fever, swollen lymph nodes Very serious in pregnant women—can lead to miscarriage, stillbirth, premature delivery, birth defects Tetanus DTaP* vaccine protects against tetanus. Exposure through cuts in skin Stiffness in neck and abdominal muscles, difficulty swallowing, muscle spasms, fever Broken bones, breathing difficulty, death (Adolescent immunizations are discussed in other relevant cases in Aquifer Pediatrics.) 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 patients age. Examples of combination vaccines are Pediarix® (DTaP, Hep B, IPV) and Pentacel® (DTaP, IPV, Hib). Vaccine Adverse Events 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 CDCs 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. Typical Early Childhood Growth Patterns 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. 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. 6-Month Developmental Milestones Gross motor Rolls over supine to prone Sits briefly unsupported No head lag when pulled to sit from supine Fine motor Reaches for objects and transfers hand to hand Looks for dropped itemss Bangs small object on surface Language Turns toward voice/begins to turn when name called 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.) © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 6/12 https://www.cdc.gov/growthcharts/who_charts.htm#The\%20WHO\%20Growth\%20Charts Social/Adaptive Feeds self/pats or smiles at reflection in mirror Demonstrates stranger recognition, the prelude to stranger anxiety Child-Proofing the Home There are several steps parents or guardians should take to childproof their home - before children begin crawling and walking. You should also recommend that grandparents or any other care environments where the children spend significant time follow these steps. These include: Installing electrical outlet covers Putting in cabinet locks Setting up stair barriers and Making sure cleaning supplies and medicines are safely stored out of reach of children. In addition, the number for poison control should be kept near the phone. For a more comprehensive list of childproofing recommendations, visit Healthy Children.org. Anticipatory Guidance at the 6-month Visit Car seat placement: The car seat should still be in the back seat, facing the rear. If the child grows out of their infant seat, parents should place a new convertible car seat still rear facing in the backseat of the car. 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: New foods should be introduced one at a time. There are no restrictions to the types of food babies can get except we do not recommend honey or cow’s milk. There is no evidence that waiting to introduce allergy causing foods like eggs, soy, peanuts, dairy or fish after 4-6 months of age prevents food allergy. Babies do not need juice but can be offered sips of water from a sippy cup or straw with meals. To prevent choking, all solid foods should be soft and easy to swallow. Stooling patterns, colors, textures may change as new solid foods are introduced and are usually due to the baby’s still developing digestive tract and are normal 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. Reach Out and Read is a nonprofit organization that gives young children a foundation for success by incorporating books into pediatric care starting at the 6-month well child visit. Learn more about the milestones of early literacy development. The 6-month-old should be expected to take two naps per day, and will probably sleep through the night. The AAPs website HealthyChildren.org has much more information on anticipatory guidance and well-child care for parents and professionals. Annual Review of the Immunization Schedule 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 years immunization requirements are available from the CDC. As noted previously, combination vaccines such as Pediarix ® (DTaP, HBV, IPV) or Pentacel ® (DTaP, IPV, HiB) may be used to decrease the number of injections at a visit and facilitate administration of vaccines at the earliest possible date. Acetaminophen and Vaccines 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. 12 Month Developmental Milestones By the time a child is 12 months old, developmental milestones include: Gross motor: Stands alone (many can walk well). Fine motor: Has a well developed, neat pincer grasp. Language: Says mama and dada (specific to that person) and one or two other words. Social/adaptive: Hands parent a book to read, points when wants something, imitates activities and plays ball with examiner. © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 7/12 https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Childproofing-Your-Home.aspx https://reachoutandread.org/about/ http://www.healthychildren.org/ http://www.cdc.gov/vaccines/schedules/ Nine-month growth chart Prognosis of Stage 4S Neuroblastoma It seems paradoxical for a cancer that has metastasized to be considered a favorable stage. However, in infants less than 1 year of age, these tumors may spontaneously regress. 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: © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 8/12 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 Weight and Length Review the weight and length as recorded, repeating any measurement that is concerning or seems inconsistent with previous growth patterns. 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 Plot your measurements on the growth chart. Introducing Difficult News 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 Initial workup for abdominal mass CBC with Differential 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. Catecholamine Metabolites (VMA and HVA) 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 A chest x-ray can identify metastases to the chest. Chest CT or MRI is necessary only if metastases are seen on x-ray. Bone Scan A bone scan can identify … Pediatrics 02: Infant female well-child visits (2, 6, and 9 months) User: Elizabeth Hernandez Email: [email protected] Date: August 20, 2021 1:26AM Learning Objectives Interpret standard growth charts to determine appropriate growth patterns in infants 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 Compare and contrast developmental surveillance and developmental screening at well child visits Distinguish normal developmental milestones at 2, 4, 6, 9 and 12 months of age Integrate anticipatory guidance and parental education on topics such as behavior, development, nutrition, safety and immunizations during well child visits Create a differential diagnosis for asymptomatic abdominal mass in a child Propose a workup for an infant with an abdominal mass List the components of a pediatrics health care maintenance office visit. Describe expected weight changes in healthy infants in the first two weeks of life. Describe how to properly obtain and record measurements of growth. Explain how to elicit the Moro reflex and its value in the neurologic assessment of infants. Describe common facial rashes of early infancy. List normal primitive reflexes of infancy. List conditions associated with abnormal red reflex in infants. List normal developmental milestone at 9 and 12 months of age. Knowledge Components of a Well-Child Visit Interval history If this is the first visit, obtain a detailed birth history. Ask if there have been any illnesses or problems since the previous visit. Using the available medical records, review any visit notes, hospitalizations, lab results, and radiology reports since the last visit. Ask about persistence or resolution of any previously identified medical issues. Ask if there are any new concerns today. Development Developmental surveillance is recommended at every well-child visit when a validated developmental screening tool is not used. Developmental surveillance may include eliciting parental concerns about development, reviewing a developmental history if available, direct observation of the child and identification of risk factors for developmental delays. The American Academy of Pediatrics (AAP) recommends developmental screening with a validated tool at the 9-month, 18- month, and 30-month visits. One of several validated developmental screening tools may be used (e.g., the Parents Evaluation of Developmental Status [PEDS], or Ages and Stages Questionnaire [ASQ]. Specific screening for autism spectrum disorder is recommended at the 18-month and 24-month visits. Growth Growth is best assessed using a standard growth chart and analyzing the growth trends for weight, height, and head circumference (in younger children) over time. Diet history Inquire about feeding practices: breastmilk or formula feeding (in infants), or types and frequency of solid 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. Obtaining a family health history is an important component of the well-child visit that can provide information on genetic, behavioral, and environmental risk factors. 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 safety risks (e.g., smokers, guns in the home, lead exposure). © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 1/12 Mothers should be screened for postpartum depression during infant well-child visits at the 1-month , 2-month , 4-month, and 6-month visits, as it can adversely affect the critical period of infant brain development. Physical exam Anticipatory guidance Each visit includes anticipatory guidance, which is your chance to help the parents anticipate the childs development and nutritional needs and to advise them regarding the childs safety. Immunizations and lab work Age-specific recommended immunizations and screening labs are performed at the conclusion of the visit. Nutrition Guidance Breast milk Breast milk is the preferred source of nutrition for most babies. Babies who are exclusively or partially breastfed should receive 400 international units of supplemental vitamin D daily beginning soon after birth. Formula-fed babies consuming less than 1 L of formula per day also need vitamin D supplementation. The American Academy of Pediatrics recommends exclusive breastfeeding until 6 months of age, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare. Formula Commercial formulas provide complete nutrition for those babies whose mothers are unable to or choose not to breastfeed. Available formulas include those made with any of: Cows milk protein Soy protein Hydrolyzed cows milk protein There are also specialized formulas that provide protein in the form of simple amino acids (the true elemental formulas). Preparing the formula Ready-to-feed formula: As the name implies, the formula is ready to feed as is. Powder: For most formulas, the ratio is 2 oz water added for each scoop of powder. Formula concentrate: The ratio is one part concentrate to one part water. There is no need to give an infant extra bottles containing water only, because formula or breast milk fulfills maintenance fluid requirements. Transition to regular cows milk Infants should take breast milk or formula until 12 months of age. According to the American Academy of Pediatrics: Young infants cannot digest cows milk as completely or easily as they digest breast milk or formula. Cows milk contains high concentrations of protein and minerals, which can stress a newborns immature kidneys. Cows milk lacks iron, vitamin C, and other nutrients that infants need. Cows milk can irritate the lining of the stomach and intestine, leading to blood loss in the stool. Cows milk does not contain the optimal types of fat for growing infants. Early Growth Most babies lose some weight in the first days after birth, then may regain their birth weight as early as 1 week of age, but are usually expected to have regained their birth weight by 2 weeks of age. Caloric Requirements of 1- to 2-Month-Olds Term infants Infants born at > 37 weeks gestational age require 100 to 120 kcal/kg/day. Average daily weight gain for terminfants is 20 to 30 grams. Preterm infants Infants born at < 37 weeks gestational age require 115 to 130 kcal/kg/day. Very preterm infants Infants born at < 32 weeks gestational age require up to 150 kcal/kg/day. The Red Reflex Description © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 2/12 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. Moro Reflex This reflex is elicited by an abrupt change in the infants head position and consists of two parts: Symmetric abduction Extension of the arms followed by adduction of the arms, sometimes with a cry The reflex is present at birth and disappears by age 4 months. The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries. Infant Rashes Neonatal acne and seborrheic dermatitis are two common rashes seen at this age. Both are benign and generally resolve over time. Neonatal acne: More accurately referred to as neonatal cephalic pustulosis, it is not true acne but an inflammatory reaction most likely due to colonization with malassezia species of yeast. Inflammatory papules and pustules usually limited to the face and sometimes scalp are common. Photo of neonatal acne. Seborrheic dermatitis: Most commonly presents as yellowish, greasy scales over the scalp, often called cradle cap. But it can also present as erythematous plaques around ears, eyebrows, nasolabial folds, and skin folds of the neck, axillae, and diaper area. Photo of seborrheic dermatitis. Primitive reflexes Primitive reflexes can be used: To evaluate the integrity of the central nervous system To detect developmental delay To assess normal development Abnormalities seen may include asymmetry, absence of appearance—or delay in disappearance—of reflexes. Primitive reflexes present at birth (in addition to the Moro) include: Moro Reflex This reflex is elicited by an abrupt change in the infants head position and consists of two parts: Symmetric abduction Extension of the arms followed by adduction of the arms, sometimes with a cry. The reflex is present at birth and disappears by age 4 months. The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries. Palmar Grasp Infant grasps examiners finger placed in open palm and tightens grasp when finger withdrawn. This reflex must disappear before the infant can begin grasping objects voluntarily. This reflex persists until 2-3 months of age. Plantar Grasp Infant flexes toes downward when examiner presses on ball of foot. This reflex must disappear before the child begins to take steps. Asymmetric Tonic Neck Reflex (Fencing Reflex) When examiner turns head to one side, infant while supine assumes “fencing posture” extending the arm on the same side as the head is turned and bending the other arm at the elbow. This reflex is one of the first steps in hand/eye coordination and must disappear before the infant can reach for objects in or across the midline. Babinski Response © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 3/12 http://www.dermnet.com/images/Acne-Infantile http://www.nizoralshop.com/img/cms/Seborrheic-Dermatitis-in-baby-yellowish-crust.jpg Infant dorsiflexes the big toe and fans the other toes when examiner strokes the lateral aspect of the foots plantar surface. This reflex is normal in children up to 2 years of age. Developmental Surveillance and Screening Evaluating a childs development should always 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 childs behaviors to expected behaviors by age) is known as developmental surveillance. Developmental surveillance generally includes assessment of milestones in four domains. 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. Screening with a validated tool is recommended at 9, 18, and 30 months of age. Specific screening for autism spectrum disorder with a validated tool is recommended at 18 and 24 months of age because these are critical periods of early social and language development. For more information on developmental screening, see the AAPs Policy Statement and Aquifers 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. Anticipatory Guidance at the 2-month Visit Solid Foods Babies are developmentally ready to begin spoon feeding pureed 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 international 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 milk each day (which is 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. Child Care Many parents appreciate receiving materials on choosing a child care center. Sleep Most babies sleep through the night by age 4 to 6 months. To help prevent sudden infant death syndrome, the AAP recommends that, for the first year of life, babies should sleep on their backs in their cribs on a firm surface, without soft objects like bumper pads, comforters, or stuffed animals, ideally, in their parents room. More information on safe sleep: AAP Updated 2016 Recommendations for a Safe Infant Sleeping Environment 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! Car Seat Safety Children under age 13 years old should not sit in the front seat. Until at least age 2 years, children should face rearward and ideally as long as possible until they outgrow their rear facing carseat. The National Safety Transportation Board and the AAP stress that the back seat is the safest place in a vehicle for children. © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 4/12 http://pediatrics.aappublications.org/content/118/1/405.full file:///documents/803 http://pediatrics.aappublications.org/content/122/5/1142.full https://www.healthychildren.org/English/family-life/work-play/Pages/Choosing-a-Childcare-Center.aspx http://pediatrics.aappublications.org/content/138/5/e20162938 The middle of the back seat 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 a crotch strap. Immunizations in Childhood These are the vaccines and the number of doses of each that children should receive through 6 years of age: Disease Vaccine Diseasespread by Disease symptoms Disease complications Chickenpox Varicella vaccine protects against chickenpox. Air, direct contact Rash, tiredness, headache, fever Infected blisters, bleeding disorders, encephalitis (brain swelling), pneumonia (infection in the lungs) Diphtheria DTaP vaccine protects against diphtheria. Air, direct contact Sore throat, mild fever, weakness, swollen glands in neck Swelling of the heart muscle, heart failure, coma, paralysis, death Hib Hib vaccine prote4cts against Haemophilus influenzae type B Air, direct contact May be no symptoms unless bacteria enter the blood Meningitis (infection of the covering around the brain and spinal cord), intellectual disability, epiglottitis (life- threatening infection that can block the windpipe and lead to a serious breathing problems), pneumonia (infection in the lungs), death Hepatitis A HapA vaccine protects against hepatitis A. Direct contact, contaminated food or water May be no symptoms, fever, stomach pain, loss of appetite, fatigue, vomiting, jaundice (yellowing of skin and eyes), dark urine Liver failure, arthralgia (joint pain), kidney, pancreatic and blood disorders Hepatitis B HepB vaccine protects against hepatitis B. Contact with blood for body fluids May be no symptoms, fever, headache, weakness, vomiting, jaundice (yellowing of skin and eyes), joint pain Chronic liver infection, liver failure, liver cancer Influenza (Flu) Flu vaccine protects against influenza Air, direct contact Fever, muscle pain, sore throat, cough, extreme fatigue Pneumonia (infection in the lungs) Measles MMR** vaccine protects against measles. Air, direct contact Rash, fever, cough, runny nose, pink eye Encephalitis (brain swelling), pneumonia (infection in the lungs), death Mumps MMR**vaccine protects against mumps. Air, direct contact Swollen salivary glands (under the jaw), fever, headache, tiredness, muscle pain Meningitis (infection of the covering around the brain and spinal cord), encephalitis (brain swelling), inflammation of testicles or ovaries, deafness Pertussis DTaP* vaccine protects against pertussis (whooping cough). Air, direct contact Sever cough, runny nose, apnea (a pause in breathing in infants) Pneumonia (infection in the lungs), death Polio IPV vaccine protects against polio. Air, direct contact, through the mouth May be no symptoms, sore throat, fever, nausea, headache Paralysis, death © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 5/12 Pneumococcal PCV13 vaccine protects against pheumococcus Air, direct contact May be no symptoms, pneumonia (infection in the lungs) Bacteremia (blood infections), meningitis (infection of the covering around the brain and spinal cord), death Rotavirus RV vaccine protects against rotavirus. Through the mouth Diarrhea, fever, vomiting Sever diarrhea, dehydration Rubella MMR** vaccine protects against rubella. Air, direct contact Sometimes rash, fever, swollen lymph nodes Very serious in pregnant women—can lead to miscarriage, stillbirth, premature delivery, birth defects Tetanus DTaP* vaccine protects against tetanus. Exposure through cuts in skin Stiffness in neck and abdominal muscles, difficulty swallowing, muscle spasms, fever Broken bones, breathing difficulty, death (Adolescent immunizations are discussed in other relevant cases in Aquifer Pediatrics.) 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 patients age. Examples of combination vaccines are Pediarix® (DTaP, Hep B, IPV) and Pentacel® (DTaP, IPV, Hib). Vaccine Adverse Events 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 CDCs 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. Typical Early Childhood Growth Patterns 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. 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. 6-Month Developmental Milestones Gross motor Rolls over supine to prone Sits briefly unsupported No head lag when pulled to sit from supine Fine motor Reaches for objects and transfers hand to hand Looks for dropped itemss Bangs small object on surface Language Turns toward voice/begins to turn when name called 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.) © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 6/12 https://www.cdc.gov/growthcharts/who_charts.htm#The\%20WHO\%20Growth\%20Charts Social/Adaptive Feeds self/pats or smiles at reflection in mirror Demonstrates stranger recognition, the prelude to stranger anxiety Child-Proofing the Home There are several steps parents or guardians should take to childproof their home - before children begin crawling and walking. You should also recommend that grandparents or any other care environments where the children spend significant time follow these steps. These include: Installing electrical outlet covers Putting in cabinet locks Setting up stair barriers and Making sure cleaning supplies and medicines are safely stored out of reach of children. In addition, the number for poison control should be kept near the phone. For a more comprehensive list of childproofing recommendations, visit Healthy Children.org. Anticipatory Guidance at the 6-month Visit Car seat placement: The car seat should still be in the back seat, facing the rear. If the child grows out of their infant seat, parents should place a new convertible car seat still rear facing in the backseat of the car. 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: New foods should be introduced one at a time. There are no restrictions to the types of food babies can get except we do not recommend honey or cow’s milk. There is no evidence that waiting to introduce allergy causing foods like eggs, soy, peanuts, dairy or fish after 4-6 months of age prevents food allergy. Babies do not need juice but can be offered sips of water from a sippy cup or straw with meals. To prevent choking, all solid foods should be soft and easy to swallow. Stooling patterns, colors, textures may change as new solid foods are introduced and are usually due to the baby’s still developing digestive tract and are normal 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. Reach Out and Read is a nonprofit organization that gives young children a foundation for success by incorporating books into pediatric care starting at the 6-month well child visit. Learn more about the milestones of early literacy development. The 6-month-old should be expected to take two naps per day, and will probably sleep through the night. The AAPs website HealthyChildren.org has much more information on anticipatory guidance and well-child care for parents and professionals. Annual Review of the Immunization Schedule 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 years immunization requirements are available from the CDC. As noted previously, combination vaccines such as Pediarix ® (DTaP, HBV, IPV) or Pentacel ® (DTaP, IPV, HiB) may be used to decrease the number of injections at a visit and facilitate administration of vaccines at the earliest possible date. Acetaminophen and Vaccines 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. 12 Month Developmental Milestones By the time a child is 12 months old, developmental milestones include: Gross motor: Stands alone (many can walk well). Fine motor: Has a well developed, neat pincer grasp. Language: Says mama and dada (specific to that person) and one or two other words. Social/adaptive: Hands parent a book to read, points when wants something, imitates activities and plays ball with examiner. © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 7/12 https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Childproofing-Your-Home.aspx https://reachoutandread.org/about/ http://www.healthychildren.org/ http://www.cdc.gov/vaccines/schedules/ Nine-month growth chart Prognosis of Stage 4S Neuroblastoma It seems paradoxical for a cancer that has metastasized to be considered a favorable stage. However, in infants less than 1 year of age, these tumors may spontaneously regress. 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: © 2021 Aquifer, Inc. - Elizabeth Hernandez ([email protected]) - 2021-08-19 21:26 EDT 8/12 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 Weight and Length Review the weight and length as recorded, repeating any measurement that is concerning or seems inconsistent with previous growth patterns. 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 Plot your measurements on the growth chart. Introducing Difficult News 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 Initial workup for abdominal mass CBC with Differential 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. Catecholamine Metabolites (VMA and HVA) 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 A chest x-ray can identify metastases to the chest. Chest CT or MRI is necessary only if metastases are seen on x-ray. Bone Scan A bone scan can identify …