PEDIATRICS REVIEW

Jennifer K. Bell MHS, PA-C

TOPICS

The newborn assessmentNewborn ProblemsDevelopment ImmunizationsSpecific Pediatric problems by system

Genetic Disorders

THE NEWBORN ASSESSMENT

Apgar scoreExam•SKIN: Erythema toxicum, mongolian spots•HEENT: fontanelles•CARDIAC: PDA•ABD/GU: hypospadias, hydrocele•MS: hip dislocation•NEURO: babinski is normal

APGARS

Done at 1 min and 5 min (may be repeated at 5 minute intervals for infants with 5 min scores <7)Score 0 1 2

Heart Rate Absent <100 >100

Respiratory effort

Absent, irregular

Slow, crying Good

Muscle tone Limp Some flexion of extremities

Active motion

Reflex Irritability

No response

Grimace Cough or sneeze

Color Blue, pale Acrocyanosis

Completely pink

Erythema Toxicum neonatorum (the rash of the newborn)

COMMON skin condition in newborns, BENIGN Appears in 50% of newborns Usually between day 3 or life and 2 weeks of life Rash: small, yellow to white papules surrounded

by red skin, usually on face, chest, back, upper arms, sometimes on thighs.

Palms and soles are not involved No treatment needed. Usually fade and disappear over 2 weeks or more

Erythema Toxicum neonatorum

Acrocyanosis

Mongolian Spots

Benign Infantile Hemangioma

Common 3 stages: Growth, Stabilization, Disappearance Most common complication is ULCERATION Usually no treatment required and a simple BIH

resolves on its own.

Further evaluation needed for : Very large or segmented hemangiomas (>5cm) Multiple hemangiomas Located over sacral spine or at the midline Located near the eye Ulceration

Physical Exam of head, face, and neck

Asses head for its shape, symmetry, and fontanelles.

Caput succedaneum: It is subcutaneous and does cross suture linesCephalhematoma: It is subperiosteal and does not cross suture lines

Cephalohematomas, go away over the course of a few weeks.

Caput succadaneum, goes away in a few days

CARDIAC

Patent Ductus Arteriosus (PDA) Failure of the ductus arteriosus to close in the first

few days of life OR reopening after functional closure.

Up to 60% in preterm infants weighing < 1500 grams

Female to male ratio= 2:1 Systolic murmur that may be continuous, and is

heard best at the upper left sternal border. MANAGEMENT:

Indomethacin: a prostaglandin synthetase inhibitor, 80% CLOSURE RATE

SURGICAL closure.

The Abdomen

Palpate the kidneys.

Anus is visualized, but digital examination is not recommended unless obstruction is suspected. Meconium is usually passed in the first 12-24 hours. An absence of the passage of meconium by 24 hours may suggest either cystic fibrosis or Hirschsprung’s Disease.

imperforate anus

Inspect the glans for the location of the external urethral meatus. In Hypospadias, the meatus is located in an abnormal ventral position. The presence of Hypospadias in the newborn indicates a contra-indication for circumcision.

Genitals : Inspect the external genitalia for ambiguity

Genitals

Testes should be descended into the Scrotum or in the inguinal canals. You can ultrasound the area to “find them” if you cannot feel them.

Hydroceles or hernias are not uncommon in newborns.

After a breech delivery, the external genitalia are often erythematous and edematous.

Musculoskeletal The purpose of this examination is to detect gross abnormalities. The

appearance of the extremities at birth usually reflects the positioning of the child within the uterus.

Examine the hips for the possibility of dislocation. The presence of asymmetric skin folds on the medial aspect of the thigh, a positive galeazzi sign, and positive ortolani and barlow maneuvers are suggestive of a dislocated femur. There are risk factors associated with hip dysplasia, but one to remember is breech position. (ALL breech babies get an ultrasound of their hips done to rule out dysplasia)

Positive galeazzi sign

Ortolani Barlow

Babinski sign is normal in newborns (> 2 years of age is abnormal)

HypoglycemiaJaundiceHearing

NEWBORN ISSUES

Hypoglycemia-<40mg/dL

Differential Insufficient glucose delivery Decreased glycogen stores Increased circulating insulin (infant of a

diabetic mother, maternal drugs) Endocrine and Metabolic disorders Sepsis Hypothermia Polycythemia Asphyxia Shock

Hyperbilirubinemia

Total Serum Bilirubin Bilirubin peaks at age 5-6 days, then normally stabilizes and

drops. Low risk zone: do nothing Low intermediate risk: possibly supplement if breastfeeding, recheck in

24 hours. Encourage to put in sunlight. High intermediate risk zone: consider bili-blanket (photo therapy) or a

bili-light. Ensure not dehydrated. May need IV fluids. Physiologic jaundice: normal Breastfeeding jaundice: lack of breastmilk Breastmilk jaundice: persists in breastfed babies for 3 weeks to 4

months. Normal.

Remember Kernicterus Bilirubin >20-25 Can lead to permanent brain damage, even death.

Hearing

Routine hearing screening prior to discharge, using Auditory brainstem responses (ABR) Otoacoustic emissions (OAE) *If a child fails, further audiologic testing

needed.

Primitive ReflexesMilestones

Development

Sucking Response, Rooting Response

Palmar Grasp, Plantar Grasp

Moro’s Reflex

Asymmetric Tonic Neck Reflex (Fencer)

Galant Reflex

Developmental Milestones

Five Major Areas of Normal Development

1. Gross motor skills overall movements of large muscles e.g., sitting, walking, running

2. Fine motor/adaptive skills involve use of small muscles of the hands ability to manipulate small objects problem-solving skills eye-hand coordination

Five Major Areas of Normal Development

3. Language skills hearing understanding language use of language

4. Personal/social skills socialization ability to care for personal needs

5. Cognitive skills ability to use higher mental processes including

comprehension, memory, and logical reasoning

                       

Gross Motor Skills progression

1 month: raises head while prone 2 month: holds head in midline, lifts chest off table 4 months: Rolls from front to back, sits with support 6 months: sits unsupported, puts feet in mouth 9 months: pivots when sitting, crawls, pulls to stand,

cruises 12 months: walks alone 15 months: creeps up stairs, walks backwards 18 months: runs, throws objects without falling 2 years: walks up and down steps without help 3 years: alternates feet going up steps, pedals a tricycle 4 years: hops, skips, alternates feet going down stairs 5 years: skips, jumps over low obstacles

Fine motor/cognitive progression

1 month: visually fixes, follows to midline, tight grasp 2 months: no longer clenches fists tightly, follows object past midline 4 months: holds hands open, responds to visual threat, follows 180

degrees, reaches with arms in unison, brings hands to midline 6 months: unilateral reach, uses raking grasp, transfers objects 9 months: uses immature pincer grasp, holds bottle, throws objects 12 months: uses mature pincer grasp, can make a crayon mark,

releases voluntarily 15 months: scribbles in imitation, builds a tower of 2 blocks 18 months: scribbles spontaneously, builds a tower of 3 blocks, turns

2-3 pages at a time 2 years: Imitates stroke with pencil, builds tower of 7 blocks, turns

pages 1 at a time, removes shoes and clothes 3 years: copies a circle, undresses completely, partially dresses,

unbuttons 4 years: copies a square, buttons, dresses self, catches a ball 5 years: copies a triangle, ties shoes, spreads with a knife.

Language Progression

1 month: alerts to sound 2 months: smiles socially 4 months: laughs, orients to voice 6 months: babbles, lateral orientation to bell 9 months: says “mama dada” indescriminately, gestures, understands

“no” 12 months: uses 2 words besides mama and dada, follows a one step

command with a gesture, waves bye bye 15 months: uses 4-6 words, follows a one step command without a

gesture 18 months: 15 words, knows 5 body parts 2 years: uses pronouns (I, you, me) inappropriately, follows 2 step

commands, >20 word vocabulary, uses 2 word sentences 3 years: uses 250 words, 3 word sentences 4 years: knows colors, says a song or poem from memory, asks

questions 5 years: prints first name, asks what a word means, knows opposites,

counts

Social Skills progression

1 month: regards race 2 months: recognizes parent 4 months: enjoys looking around 6 months: recognizes that someone is a stranger 9 months: explores environment, plays pat-a cake or peek a boo 12 months: imitates actions, comes when called, cooperates with

dressing 15 months: uses a spoon and a cup 18 months: copies parents in tasks (cleaning), plays in company of

other children 2 years: parallel play, possibly chase games 3 years: group play, shares toys, takes turns, knows full name, age,

gender 4 years: tells “tall tales”, plays cooperatively with a group of

children 5 years: plays competitive games, abides by rules, likes to help in

household tasks.

Hep BRotavirusInfluenzaPneumococcalHIBPolioDtapHep AVaricellaMMRHPVMeningococcus

The schedule and also details about the conditions

Immunizations

If you memorize a typical schedule of immunizations at well child visits, you will probably have a hard time missing a vaccine question regarding timing of vaccinations.

FIRST A HINT

Hep B

Transmission: percutaneous or mucosal exposure to blood or body fluids, including contact with contaminated surfaces

Chronic HBV infection: 25% die prematurely from cirrhosis or liver cancer

Recommended: birth, 1-2 months, 6-18 months

3 dose schedule for adolescents and adults

Tetanus Diptheria and Pertussis DTaP, Tdap, Td

2 months, 4 months, 6 months of age completes initial series with boosters recommended at 18 months and between 4&6 years of age

Adults should have tetanus booster (Td) every 10 yrs

Tdap age 11 and older NEW MOMS!!

Diptheria

Bacterial infection spread by respiratory droplets

Sore throat, low-grade fever Obstructive grayish membrane

Pertussis

Whooping cough Bordetella pertussis Spread by respiratory droplets Treat with Erythromycin, and treat close

contacts

Tetanus

Lockjaw Clostridium tetani (anaerobic bacteria

found in soil) Toxin proliferates in wounds Treatment with antitoxin Signs: severe muscle spasm, trismus

Rotavirus

Most common cause of severe gastroenteritis in infants and young children

Near universal infection by age 5 years U.S. – vaccine saves baby severe

dehydration, hospitalization 2-3 doses at 2/4/6 months

Influenza

Yearly dose Starts at age 6 months Avoid if allergy to eggs

Inactivated and Live are available. Do not give live vaccine to pregnant women.

Pneumococcal

All children 4 doses: 2,4,6, 12-15 months After age 2 in certain populations:

asplenics, sickle cell, complement deficiency

HIB

Prevents Meningitis, Epiglottitis, Pneumonia

HIB: bacterial infection spread by respiratory droplets

4 doses: 2, 4, 6, and 12-15 months

IPV-Poliovirus

Fecal-oral transmission Up to 95% of infections are

asymptomatic Maintain high immunization rates

Infections in Amish, 2005 29 countries reported wild poliovirus to

WHO in 2009 or 2010 (plane ride away) IPV schedule: 2, 4, 6-18 months, 4-6

years

Hep A

Fecal-oral transmission Food-borne outbreaks

PA, 2003 (Chi-Chi’s, green onions) 601 cases, 124 hospitalizations, 3 deaths

Risk factors include child or employee in day care, travel

2 doses at least 6 months apart Recommended at 12-23 months

MMR

Live vaccine First dose at 1 year, second dose at 4-6

years of age.

Measles

Begins behind the ears, and in 24-36 hours it spreads to the trunk and extremities

In 3 days it reaches its maximum intensity and fades after 5-10 days.

Koplik spots VITAMIN A

Reduce morbidity and mortality in measles

Mumps

Paramyxovirus Spread by respiratory droplets Signs and symptoms:

Fever with inflammation and swelling of Parotid glands, Orchitis is possible

Rubella

Most important consequences are to the unborn: miscarriages, stillbirths, fetal anomalies (congenital rubella syndrome).

Varivax

Varicella Zoster 2 doses: 1 year of age and a booster at 4-6

years of age

Spread by respiratory droplets Signs: fever, flue-like symptoms, blistery

itchy rash that crusts over Contagious until the rash becomes crusted Reactivations later in life are possible

(shingles)

HPV

Approved for girls and boys ages 9-26 years of age.

3 doses Dose 1 Dose 2, in 2 months Dose 3, in 6 months from first dose

Meningococcus

Protects against Neisseria meningitidis Meningitis septicemia

High risk groups Dormatory living Military

Booster dose now approved, so 1 dose at age 11, then 5 years later a booster dose.

Some Select Pediatric Problems

•Cryptorchidism•Cradle Cap•Diaper Rash•Fifths disease: Erythema Infectiosum•Roseola infantum (sixth disease)•Kawasaki’s Disease

•Nasolacrimal duct obstruction•Strep Throat•Coarctation of the Aorta•Tetrology of Fallot•Pyloric Stenosis•Intussusception

Nasolacrimal Duct Obstruction 1st few weeks of life Eye drainage and crusting Treatment: you can clean the crusts, local

massage, if becomes infected tx that infection. If not resolved on its own by one year-refer

Strep Throat: Group A (GABHS)

Strawberry tongue Scarletina rash: fine reddish sandpaper

like rash sparing the palms and soles

Symptoms: Exudative tonsilitis Ant cervical lymphadenopathy Fever > 101F Absence of URI symptoms Abdominal Symptoms

Cardiac stuff

Coarctation of the aorta Narrowing of aorta causing systolic murmur

and differential in pulses in upper and lower extremities

Tx: surgery Tetralogy of Fallot

VSD, RVH, Pulmonic Stenosis, Overriding Aorta

Tx: complete surgical repair

Pyloric Stenosis

In first month of life More common in first born males PROJECTILE VOMITTING Palpable “olive mass” Dx: ultrasound, barium swallow Tx: surgery

Intussusception

Telescoping of the bowel Triad: vomiting, abd pain, CURRANT JELLY

STOOL DX and TX: barium or air enema

Cryptorchidism

Increased risk of testicular cancer later in life

Undescended testes Tx: surgery

Seborrheic Dermatitis (cradle cap)

Seborrheic Dermatitis (Cradle cap) Very common rash characterized by

erythema and greasy scales Can affect the face, ears, and neck Usually self limiting, but can be treated:

White petroleum Ketoconazole Hydrocortisone cream

Diaper Dermatitis

Causes: Candida (satelite lesions)

Treatment: antifungal (lotrimin) Prolonged contact with urine or stool

causes skin breakdown Barrier (desitin otc cream)

Bacterial causes Strep B, “Perianal streptococcal infection”

(Amoxil)

Diaper Rash

Candida=SATELLITE LESIONS

Prolonged Contact with urine/feces

Erythema Infectiosum-AKA Parvovirus B19 or Fifth disease

Common, Mildly contagious Appears in epidemics, children between

5-14 years of age Transmitted via respiratory route and

infected blood Can be asymptomatic Prodromal symptoms

Mild, pruritus, low-grade fever, malaise, sore throat (asymptomatic)

Erythema infectiosum-3 phases

Stage 1: facial erythema (slapped cheeks) Red papules coalesce forming fiery red, slightly edematous,

warm plaques that are symmetric on both cheeks and spare the nasolabial fold and circumoral region.

Fades in 4 days

Stage 2: Net pattern erythema Erythema in a fishnet-like pattern begins on the extremities 2

days after the facial erythema. Extends to the trunk and buttocks fading in 6-14 days

Stage 3: recurrent phase The eruption fades and then reappears in previously affected

sites on the face and body during the next 2-3 weeks. Triggers: emotional upsets, sunlight, temperature.

Roseola

80% of all children by age 1, 90% by age 2 Most cases are asymptomatic OR occur with a fever of

unknown origin and NO rash Most cases between 6 months and 4 years Typically: very high fever, fever subsides and the

rash appears. Febrile seizures common

Kawasaki Disease: AKA Mucocutaneous lymph node syndrome

Children: 7 weeks-12 years of age. (rare in adults)

An acute multisystem vasculitis of unknown etiology (likely infectious cause)

Cardiovascular manifestations are the main cause of morbidity

Down SyndromeKlinefelter SyndromeTurners SyndromeMarfan Syndrome

Genetic Disorders

Down Syndrome-Trisomy 21

Mental retardation Single palmar crease Hypothyroidism Flat occiput, epicanthal folds, large

tongue Congenital heart disease

Turner Syndrome (XO)

1/2500 affected Physical characteristics

Short stature Broad chest with widely placed nipples Low hairline Low set ears Webbed neck Amenorrhea Sterility Congenital heart disease, DM, vision problems,

hypothyroidism, autoimmune diseases

Turner Syndrome

Kleinfelter Syndrome (XXY)

Most common sex chromosome disorder 1/500 Long legs small, firm testes and gynecomastia Osteoporosis Motor delay or dysfunction Language and speech problems Attention deficits Behavioral and psychosocial problems Dyslexia or reading dysfunction

Decreased fertility (thought to be the cause of 2-3% of male infertility)

Kleinfelter Syndrome

Marfan Syndrome

Autosomal dominant, chromosome 15

Systemic connective tissue disease

Tall stature, long arms and fingers Commonly scoliosis and pectus

excavatum Displaced ocular lens Mitral valve prolapse Aortic root dilation-aortic

regurgitation Aortic dissection and rupture

GOOD LUCK TO YOU ALL!!!

The Last time you will likely ever endure a lecture with me