Peds exam 1

Rooting

Rooting

4 months. Stroke the corner of your baby’s mouth with nipple, they turn their head toward it to nurse.

Sucking

4 months. When something touches a baby’s palate, he or she starts to suck it.

Moro

2 months. Startle reflex , arms goes out legs goes in

Stepping

2 months. Holding baby upright baby will start to move legs as if he/she is walking or trying to take steps.

Tonic neck

5-7 months. If neck goes one way, arm stretches out that way

Palmar grasp

5-6 months. Place object in infants hand, they will grasp it

Babinskis

12-24 months. Scratch baby foot, toes will go outward

Infancy

Piaget: sensimotor

Erik son: trust vs mistrust

Anterior fontanelle

9-18 months

Posterior fontanelle closure

6-8 weeks

Infant weight

Doubles by 4-6 months, triples by 12 months

How much do infants grow by

1/2 - 1 inch per month

Infant teeth

lower incisors usually around 4-6 months of age

2 month milestones

• obligate nose breathers up until now

• Moves head side to side

• Tracts with eyes

• Holds head up on stomach

4 months

• begins to like play

• Cooing/ babbling (copies noises)

• Can hold and reach for toys

• Rolls stomach to back

6 month milestones

• rolls from back to front

• Will start to develop stranger anxiety

• Sit briefly without support in tripod position

• Transfer object from one hand to other

8-9 month milestones

• sit without support

• Starts crawling

• Pincer grasp

• Pulls to stand

• Starts to develop object permanence

1 year old milestones

• 3-5 words

• Should walk or take steps holding hand

• Can put objects in containers

• Follow simple command

• Separation anxiety

Trust vs mistrust

Infants building trust with caregiver that needs are going to be met. Must respond to cry: rock or swaddle

Sensimotor

All things learned are based on experiences or trial and error. Begin to develop object permanence. Baby only able to use senses to understand/ learn

Infant play

Younger infants: toys that can be batted with hands and kicked with feet, toys with contrasting patterns

Older infants: toys that light up or make noise, soft dolls, teething toys, board books, large stackable blocks

Toddler

1-3 years

Toddler growth and development

• starting to walk, wants to move

• Beginning bowel and bladder control

• Switch from formula to good

• Beginning language

• Stronger immune system

• By 2, 4x birth weight

• Head to chest circumference evens out

Toddler motor development

• crawls up steps by 15 months

• Eats with a spoon by 18 months

• Runs by 24 months

• Kicks a ball and jumps with 2 feet by 24 months

• Pedals a tricycle by 36 months

• Walks up and down stairs by 36 months

When do toddlers crawl up steps by?

15 months

When do toddlers begin to eat with spoons?

18 months

When do toddlers begin to run?

24 months

When do toddlers begin to kick a ball and jump?

24 months

When do toddlers pedal a tricycle?

36 months

When do toddlers walk up and down stairs?

36 months

What language comes first to toddlers?

Receptive

Echolalia

When kids repeat words without knowing what it means.

How many words should children know by age 2?

50 words, 2 word sentences, name body parts

Autonomy vs shame and doubt

Begin to understand that they are separate from caregiver and will try to test independence. Focused on developing a sense of personal control and sense of independence. Learning new skills such as picking the toys to play with/ eat/ wear. Not able to see a situation from another persons point of view.

Parallel play

Play along side one another

Appropriate toys for toddlers

• stacking blocks, push pull toys, dolls, puzzles with large pieces, large crayons.

Preschool age

3-5

Initiative vs guilt

• children will assert themselves through play. Will begin to make up games and initiate activities with others. If unable to due to critism or control, will develop sense of guilt. Starts to ask more questions, if parents see it as a nuisance child may develop guilt

Preoperational

Age 2-7

• development of language, memory, imagination

Preschool age play

• imaginary and creative play

• Make believe is activity of choice

• Create characters and stories that involve dressing up

• Coloring, molding clay, simple board games

School age

6-12

Industry vs inferiority

• teachers have important role in teaching them to read/ write. If encourage they begin to feel confident, if limited they will begin to doubt abilities

When do children begin to lose their teeth?

6 years old

Concrete operational

• age 7-11

• More logical and methodical

• Less egocentric, more aware of outside world

What age does gender dysphasia occur?

9/10

What age do children usually identify a best friend?

Age 7

School age play

• cooperative play

• Able to play team sports

• Play alone, video games, reading, writing

• 60 minutes of activity

Adolescence

• early adolescence: 10-13

• Middle adolescence: 14-17

• Late adolescence: 18-21

Formal operational

11 to adulthood

• able to grasp abstract concepts and relationships

Identity vs role confusion

• search for a sense of self and personal identity

• Want to fit into society

Adolescence body

• increase risk of bone fractures/ sprains

• Increase of body fat in women/ lean mass in men

Adolescence social and emotional development

• begin to separate from parents

• Peer influence is high

• Gender identity influenced by sociocultural and psychological factors

• Body image

Tanner stage males

• stage 1 none

• Stage 2 no change in penis, enlarged scrotum, hair scant

• Stage 3 increase length, increased scrotum, hair darker

• Stage 4 increase breadth, scrotum darkens resembles adult but less quantity

• Stage 5 adult size, adult distribution

Tanner females

Stage 1: no change, no pubic hair

Stage 2: breast elevated, aerial enlarged, scant pubic hair

Stage 3: breast and aerial enlarged no contour definition between, Pubic hair darker and curly

Stage 4: aerial forms mound separate from breast, pubic hair resembles that of adult but scant

Stage 5: adult appearance, nipples project , pubic hair adult distribution

Corrected age

Actual age - weeks/months of prematurity = corrected age

MMR vaccine

12-15 months

What vaccine is given at birth

HepB

2 month vaccines

Rv, hepB, dtap, IPV, PCV13

Inactivated vaccine

Virus killed during process of making vaccine.

• does not produce full immunity

• May need boosters

Inactivated vaccine examples

Rabies, hepA, flu vaccine, polio

Conjugate

Protects against bacteria with polysaccharide coating, allows immune system to recognize and react

• examples: hib

Toxoid

Protects against bacteria that causes toxins, uses weakened form of toxin

• diphtheria, tetanus

Live vaccines

Uses weakened or attenuated form

• immune response similar to natural infection

Common side effects after vaccinations

• fever up to 102

• Redness or small amount of swelling at injection site

• Increased fussiness in 24 hours after

• Increased sleep in 24 hours

• If patient has fever, hold off on vaccinations

Where to give vaccines for infants

Anterolateral aspect of thigh 5/8- 1 inch

Toddler shots

Anterolateral thigh 1 inch

Children shots

Deltoid 5/8 - 1 inch

Adolescents shot

Deltoid 1 - 1 1/2 inch

Strabismus

Misalignment of the eye, common up to 6 months

Head lag

Having a hard time maintaining head control when picking them up.

Infant eyes

Should be able to focus on objects by 3-4 months

Infant respiratory

Less than 6 years, respiratory movement is mostly abdominal, expansion should be symmetrical. Almost circular diameter

Infant heart/ perfusion

Less than 7 years old, apical pulse at 4th intercostal space

Sinus arrhythmia

Heart rate increases with inspiration and decreases with respiration

Genu varum

Bowleg

Genu valgum

Knock knee

Differences between children and adults

• have larger heads compared with bodies

• Larger tongues

• Shorter narrower airway that is more elastic and more collapsible

• Belly breathers

• Higher fluid requirements

• Higher metabolic rates

Infant assessment position

If unable to sit, lay prone or supine, preferably in parents lap. If able to sit alone, sit on parents lap

Infant assessment sequence

Head to toe. Auscultation , palpate, percuss. Perform traumatic procedures last (eyes, ears, mouth)

Infant assessment preparation

Completely undress if room is okay

• have parents help hold for exam of eyes, ears, mouth

• Can use sweetease for comfort.

Toddler assessment position

• sitting or standing on/by parent

• Prone or supine in parents lap

Toddler assessment sequence

• inspect body area through play. Count fingers, tickle toes

• Introduce equipment slowly

• Traumatic procedures last

Toddler preparation

• have parents remove outer clothing

• Allow patient to inspect equipment

• If cooperative talk about exam in short phases

• Praise when cooperative

How to communite with toddlers?

• allow toddler to touch safe medical equipment

• Explain to toddler what you are doing in simple terms

• For blood pressure “I am going to give your arm a hug”

Preschool assessment position

Standing it sitting, whatever preference

Preschool assessment sequence

• if cooperative proceed in head to toe

• If uncooperative proceed same as toddler

Toddler preparation assessment

• request self undressing

• Offer equipment for inspection, briefly demonstrate use

• Make up story about procedure “I’m seeing how strong your muscles are” for bp

• Use paper doll technique (pretend to give med to doll)

• Give choices when possible

• Expect cooperation, use positive statements “open your mouth”

School age child assessment position

Prefer sitting

School age child sequence assessment

• proceed in head to toe direction

School age child assessment preparation

• respect need for privacy

• Give gown to wear

• Explain purpose of equipment and significance

• Teach about body function and care

Adolescent assessment preparation

• allow to undress in private

• Respect privacy

• Explain finding during exam in matter of act way

• Emphasize normalcy of development

Temperature under 2 years?

Rectal temps

How often should you feed infants?

Every 2-4 hours

How long should you breast feed?

6 months then incorporate rice cereal, can later start slowly introducing other foods

How often should you introduce new food?

Every 5-7 days

Risk factors for SIDS

• maternal smoking

• Maternal alcohol use

• Co sleeping

• Prone sleeping

• Soft bedding

• Prolonged qt interval

How should babies sleep?

On their back, safe crib no loose bedding, toys, blankets

Toddler nutrition

• can switch to whole milk at 12 months

Food jag

When toddlers only eat certain foods