Pediatric Pt

4 principles of child development

1. development follows a predictable pathway

2. range of “normal” is wide

3. various physical, social, enviro, and medical factors affect development

4. you must taper your history and PE to child’s development level

Is slow development of milestones concerning?

no necessarily, but concerned about LOSS of milestones

what to do at every single visit for ped pt?

healthy promotion and counseling (for parents mostly)

screening for ped pt (7)

1. vision

2. BP

3. hearing

4. dental

5. height/weight/BMI

6. lab work

7. TB

when is the neonatal period

days 1 -28

postneonatal period

days 29-1 yo

when is a neonatal most responsive

1-2 hrs after feeding

when is the first dental exam for ped pt

1 years old

important things to observe of newborn at first visit

• observe parental bonding

• observe newborn feeding

Apgar scores occur…

immediately after birth 1 min and 5 min after birth

what does Apgar score assess

the infant recovery from birth and adaption to external world

Apgar scoring

0-2 scale fro each category (3 point scale)

total 0-10

can continue with scores every 5 min until > 7

when to stop apgar exam

when score is 8 can continue with medical exam

What does Apgar look at (5)

• respiration, crying

• reflexes, irritability

• pulse, HR

• skin color of body and extremities

• muscle tone

gestational age preterm

<34 wks

gestational age late preterm

34-36 wks

gestational age term

37-42 wks

gestational age posterm

>42 wks

extremely low birth weight

<1000 grams (2.2 lbs)

very low birth weight

<1500 g

low birth weight

<2,500 g

normal birth weight

>2500 g (>5.5 lbs)

small gestational age (SGA) percentile

<10th

appropriate for gestational age (AGA) percentile

10-90th

large for gestational age (LGA) percentile

>90th

why are you concerned about large gestational age

gestational diabetes→ fetus may develop hypoglycemia

birth weight increases by …. in 1st year and height increases by …

triples

50%

pathway of neurological development

central → then peripheral

Head control, extremity control then use of hands and fingers

physical milestones

1mo

6mo

12mo

1mo: head control

6mo: sits with support

12mo: walks

cognitive/language milestones

1mo

6mo

12mo

1mo: responds to sounds

6mo: waves “bye-bye”

12mo: says 1-3 words

social and emotional milestones

1mo

10mo

1mo: smiles

10mo: imitates activities

normal Apgar score in 1 min

8-10 normal

5-7 some nervous system depression

0-4 severe depression, immediate resuscitation

normal 5 min Apgar score

8-10 normal

0-7 high risk for CNS or other organ dysfunction

Apgar score of HR

0: absent

1: < 100

2: > 100

Apgar score of Resp effort

0: absent

1: slow, irregular

2: good, strong

Apgar score of muscle tone

0: Flaccid

1: some flexion

2: active motion

Apgar score of reflex irritability (reaction to suction of nares with bulb syringe)

0: no response

1: Grimace

2: crying, sneezing, cough

Apgar score of color

0: blue, pale

1: pink body, blue extremities

2: pink all over

general survey and VS

1. Length → Lying down

2. Weight → Naked or dry diaper

3. Head circumference → Up to 2 y/o

4. Blood pressure → May be taken at birth & Routinely after 3 years

when are checkups during first year

3-5 days, 1mo, 2, 4, 6, 9, 12

Infant Periodicity Schedule

normal pulse < 1mo

90-190 bpm

normal pulse 1-6mo

80-180 bpm

normal pulse 6-12mo

75-155 bpm

normal respiration infant (birth - 1year)

30-60

normal respiration toddler (1-3 years)

24-40

normal respiration preschooler (3-6 yers)

22-34

normal respiration school age (6-12 years)

18-30

normal respiration adolescents (12-18 years)

12-16

what to do if infant 0-3mo has temp >100.4

ER!! need meningitis workup bc BBB susceptible

turgor in infants should be …

rapid

texture skin in infants should be….

smooth and soft

Lanugo in infants should be …

fine hair especially on shoulders and back

Cutis Marmorata

• Vasomotor changes

• Response to cooling or chronic exposure to radiant heat

• Bluish, mottled appearance

• a/w preemies, congenital hypothyroidism, down syndrome

Acrocyanosis

• Bluish discoloration to hands and feet

• Due to exposure to cold

• Common in the first few days of life

• Disappears with warming

What is Acrocyanosis does not disappear with warming

consider congenital heart disease if it does not or if present with central cyanosis

Vernix Caseosa

• Cheesy white material present at birth

• Composed of sebum and epithelial cells

Café-au-lait Spots

• Light brown lesions

• Usually of no significance

• >5 concerning

>5 Café-au-lait Spots a/w …

neurofibromatosis- nerve tissue grows tumors, can be benign or can cause damage to surrounding structures

Miliaria Rubra

• Vesicles with erythematous base

• Usually on the face and trunk

• Due to obstruction of the sweat glands

• Disappears in weeks

Miliaria Rubra is due to …

obstruction sweat glands

where is Miliaria Rubra most common

face and trunk

Erythema Toxicum

• Rash appears within 2-3 days after birth

• Erythematous macules with central pinpoint vesicles

• Diffuse over the entire body

• “flea bitten” appearance

• Unknown etiology

• Disappear within one week of birth

Pustular Melanosis

• Small vesiculopustules → flaking → brown macules

• Present at birth

• m/c in African American infants

• Can last several months

Milia

• Pinhead like, smooth white pearly cysts

• Appears within a few weeks of birth

• Disappears in a few weeks

• Can occur in adults

• Retention of sebum in the sebaceous glands

Where is Milia most common

nose, chin, forehead

Cradle cap

• Seborrheic Dermatitis

• Common inflammatory skin condition

• White-yellowish scaly plaques

• Typically on the scalp

• Self-limiting

• Can use baby oil & a soft brush

Eczema

• Hypersensitivity reaction

• a/w allergies, asthma & atopic dermatitis

• Can grow out of it or become a chronic skin condition

• Scaly, dry, itchy rash

• Can blister, weep or peel

Tx Eczema

• Gentle cleansers

• Non-perfumed baby creams

• Baby mittens

• Treat super infection

Diaper Dermatitis

• Contact dermatitis

• Erythematous, painful irritant rash

• Due to moisture in the diaper

Diaper Dermatitis Tx

OTCs, frequent diaper changes, or Rx creams

Physiologic jaundice

• ½ of all newborns

• Occurs on the 2^nd or 3^rd day of life

• Peaks at the 5^th day, disappears in one wk

• Progresses from head to toe

tx of Physiologic jaundice

natural sunlight

jaundice that occurs first 24hrs likely …

pathologic

Pathologic jaundice

• Within 24hrs of birth

• Persists beyond 2-3 wks

• Levels may be dangerously high

Hemangioma

• Flat, irregular, vascular markings

• AKA salmon patch, strawberry marking, stork bite, angel kisses, telangiectatic nevus, capillary hemangioma

• Usually benign markings

• Usually fade over time

Slate Blue Patches/Slate Gray Nevi most common in

dark skinned babies

Slate Blue Patches/Slate Gray Nevi

• Flat blue, blue-grey skin markings

• Appear at birth

• AKA congenital dermal melanocytosis

• Formerly referred to as Mongolian Spots

• Benign

• *important to note! so not confused with bruising

Impetigo

• Yellow, crusty

• Honeycomb-like rash

• Staph infection

Molluscum Contagiosum

• Poxvirus

• Umbilicated, flesh colored papules

• Can multiply

• Can spread from person to person

• Months à years to resolve

1/3 of the infants body weight is the …

head

Sutures

Tissues that separate the bones of the skull

Lambdoidal, sagittal, coronal, metopic

Fontanelles

Areas where the major sutures intersect

Anterior & posterior fontanelles

which Fontanelles close first

posterior close 1st: 2 mo

anterior: 4-26 mo but most common 7-19 mo

molding of head

Overlap of the cranial bones at birth in order to fit out of the birth canal, disappears in a few days

Caput succedaneum

Asymmetric head swelling that crosses the suture lines

Caused by prolonged pressure on head during birth

–Resolves in 1-2d

Caput succedaneum typically resolves in …

1-2 days

Cephalohematoma

Localized head swelling, does not cross the suture lines, due to the trauma of birth

Cephalohematoma usually resolve

3 wks

Positional plagiocephaly

“flat head”

Due to positioning of the infant, favoring of one side

macro/micro cephaly

important to measure head circum

hydrocephalus

• Increased CSF à ventricular dilation

• Bulging anterior fontanelle

• Deviation of eyes downward

most genetic syndromes have ….

abnormal facies

ex: Down Syndrome

abnormal facies associated with Down Syndrome

flat nose and face

upward slanting eye

widely sep first and second toe and increases skin creases

single palmer crease, short fifth finger that curves inward

By … month they should be fixating on objects

one

By … months coordinated eye movements

1.5 to 2 mo

….mo baby will start to reach for things

3

absence of red reflex indicate

• retinoblastoma

• congenital cataracts

• retinal detachment

low set auricles can be associated with …

renal dz

small or deformed ears may indicate …

congenital defect

acoustic blink reflex

sudden noise that causes infant to blink