1
Q
Newborn physical
- history
A
- family
- prenatal
- delivery
- if NICU, get details (intubated, O2, etc.)
2
Q
Newborn physical
- Vitals
- skull
A
Vitals • Temp initially reflects intrauterine environment, if mom was febrile, baby will also be warm • HR 150-200 • RR 42-70/80 • BP around 60/40
Fontanels and skull
• Feel for open posterior and anterior
• Feel for open spaces between skull plates
3
Q
Newborn physical
- Eyes
- Nose
- Oropharynx (inc natal teeth)
A
Eyes
• Ensure red reflex
• Ok if deconjugate or just look at you with one eye, normal up to 6 months
Nose
• Often stuffy from delivery
• May need suction
Oropharynx
• Ensure palate is intact and no cleft
• Bifib uvula → submucosal cleft palate
Natal teeth: uncommon. Are primary teeth, if loose need to be pulled. Inform parents will not have a tooth until adult tooth comes in
4
Q
Newborn physical
- heart
- lungs
A
Heart:
• Listen for murmur
• Pulse ox on hand and feet to test for CHD, readings should be within 3 points. If not, repeat in one hour. If continues to be >3 points, echo to rule out CHD
• Femoral pulse is good screen for COA
Lungs
• Normally clear bilaterally.
• If premature, might have crackles
• Can have aspiration if meconium was present
5
Q
Newborn physical
- Belly
- Baby boy
A
Belly
• Ensure 3 vessel cord: one vein two arteries
• Belly should be soft, no masses, no abd wall defect (normally find on prenatal US)
Boy
• Ensure both testicles are descended
• Hypospadias – can be hard with foreskin (only pull foreskin back as far as can without tearing)
6
Q
Newborn physical
- hips
- legs
- back
A
- Hips: check for dysplasia
- Legs: lots of congenital positioning that will go away with time, reassure parents
- Back: Spine complete, look at buttock and sacral area for spinal cord issues (cleft, hair tuft, etc.)
7
Q
Dubowitz exam
A
used on (usually premature) babies to determine gestational age if unknown
8
Q
APGAR
- timing and significance
- scoring
A
• 1 minute: not as significant, reflects birth experience
• 5 minutes: more significant, if low, redo again at 10 minutes to see if baby is improving
• Low 5 and 10 minute more sig for long term issues
- 7-10 is normal, newborn in good condition
- <7 indicates baby needs assistance transitioning
9
Q
APGAR
- 5 categories
A
- HR
- Respirations
- Color (perfusion)
- muscle tone
- response to stimulation/reflex irritability
10
Q
APGAR
- HR scoring
A
- Absent = 0
- <100 = 1
- > 100 = 2
11
Q
APGAR
- Respiration scoring
A
- Not breathing = 0
- Weak cry, irregular breathing = 1
- Strong cry = 2
12
Q
APGAR
- Muscle tone scoring
A
- Limp, flaccid = 0
- Some flexing or bending = 1
- Action motion = 2
13
Q
APGAR
- Response to stimulation/reflex irritability scoring
A
- No response = 0
- Grimace = 1
- Vigorous cry or withdrawal = 2
14
Q
APGAR
- Color (perfusion) scoring
A
- Pale or blue = 0
- Normal color body, blue extremities = 1
- Normal color = 2
15
Q
Growth
- types of growth chart
A
- height
- weight
- BMI
- head circumference
16
Q
Some deets about baby weight
A
- Will lose weight after birth, up to 10% is ok, >10% is problem
- Should regain birth weight by 2 weeks
- First three months should gain 1 oz per day
- Birth weight doubles by 4-6 months and triples by 12 months
- Some babies need extra calories: CHD, neuro defect (seizures, etc.)
17
Q
Some deets about baby length/height
A
- Ave length is 20”
- By age 1 birth length increases 50%
- Height at age 2 is about ½ adult height
- Ave growth until puberty is about 2” per year
18
Q
What should head circumference percentile track with?
A
height, not necessarily weight, think fat baby :)
19
Q
Failure to thrive
- definition
A
- no universal def
- <3rd percentile for weight
- Weight is <80% ideal for age
- Decrease 2 percentiles in weight when height is not changing
20
Q
Failure to thrive
- 3 causes
A
- Organic dz: cardiac, neuro, GI (reflex, chronic diarrhea, celiac), CF, chronic infection including UTI
- Environmental deprivation
- No explanation
21
Q
FTT
- W/u
A
History
• Breastfeeding: how long does baby nurse, both sides? What do breasts feel like afterwards: empty or full? Have you pumped? How much? If you pump afterwards how much milk is there?
• Formula: show me how you make it (ensure not diluting too much)
PE
• Careful measurement, re-measure if needed
• Signs of chronic illness
Labs • CBC: chronic infection or anemia • Chemistries include liver, kidney, electrolytes • Thyroid: congenital hypothyroidism • UA: chronic infection
22
Q
Nonorganic fit cause of FTT
A
- Parental depression, other psych illnesses
- Abuse/neglect
- Financial: can’t afford formula, will stretch by thinning out with water
23
Q
Development
- 4 categories to evaluate
A
- gross motor
- fine motor
- speech and language
- social/personal
24
Q
Causes of speech and language delay
A
- mental retardation
- hearing loss
- developmental delay
- expressive language disorder (talk constantly but gibberish)
- bilingual
- psychosocial deprivation
- autism
- elective mutism
- receptive aphasia
- CP
25
WCC
| - overview
- Provides info about development, diet, general care, immunizations, other important advice for parents. Attention is paid to whether infant has met normal developmental milestones. Height, weight, head circumference are recorded and plotted on growth chart.
- More frequent at first while development is most rapid
- Each visit includes complete PE
- Timing: 1, 2, 4, 6, 9, 12, 15, 18 months and then yearly until 21
26
Newborn visit
- timing
- development
- AG
- plans/orders
- Done within days of birth, might have many fu visits until establish baby is growing
```
Development
o Equal movement both sides
o Makes eye contact
o Responds to noise
o Lifts head when prone
o Palmar grasp
```
```
Anticipatory Guidance
o Car seat (and at all WCC after this!)
o Immunization schedule
o Sibling adjustment
o Umbilical cord care
o Circumcision care
o Sleep position (back is best)
```
Plans orders
o Bilirubin
o Weight check in ____ days
27
Infant reflexes
- Moro: startle response to falling. Throw arms out, clench fist, appear startled, eyes wide open, usually cry
- Tonic neck: rotate relaxed head when baby is on back, arm on side face is facing will extend and opposite arm will flex and hand will clench
- Grasp: will grasp finger placed in palm (gone by 4 months)
- Plantar grasp: same as hand grasp except with toes, foot will plantar flex
- Rooting: stroke cheek, infant will turn to side and suckle
28
1 month WCC
- development
- AG
- Plans/orders
```
Development
o Awake longer periods
o Hearing
o More attentive
o Eye contact
o Mom: depression scale (Edinburgh Postnatal Depression Scale)
```
```
Anticipatory guidance
o Car seat
o Skin care
o Nasal hygiene
o Sleep position
o Return to work/child care
```
Plans orders
o Review newborn screening results
29
2 month WCC
- development
- AG
- Plans/orders
Development
o Push up slightly on forearms while on belly
o Happy cooing/smiling = mom bonding (which she has EARNED)
o Weight bearing on legs
o Some head control
o Follows to midline
```
Anticipatory guidance
o Delay introduction of solids
o Fever control
o Smoke/CO detector
o Water heater set to 120
o Falls
```
Plans/orders
o Immunizations
30
4 month WCC
- development
- AG
```
Development
o Push up on arms
o Hands together
o Follows 90 deg
o Grasps toys
o Laughs, squeals, babbles
o Rolls front to back
o Head steady
```
Anticipatory Guidance
o Risk of walkers/jumpers
o Car seat
o Solid food introduction
31
6 month WCC
- development
- AG
- Plans/orders
```
Development
o Can sit up
o Transfers objects
o Turns to sounds
o Rolls both ways
o Smiles at mirror
o Coos, laughs, babbles
o Up on all 4s, prob not yet crawling
o Start feeding solids (only start at 4 if need extra calories, rather eat solid food than formula)
```
```
Anticipatory Guidance
o Introduce a cup
o Baby proofing house
o Discourage sleeping with bottle
o Dental hygiene
o Fluoride intake review
```
Plans/Orders
o Flu shot starts at 6 mo
32
9 month WCC
- development
- AG
```
Development
o Babbling
o Pulls to stand, cruises, creeps = BUSY
o Holds bottle
o Finger feeds
o Mama, dada, specific
o Responds to name/no
o Explores
o Peek-a-boo
```
Anticipatory Guidance
o Poison
o Finger foods
o Sleep problems: pattern and ritual needed
o Reinforce baby proofing
o If baby has teeth, need to brush! No bottles in bed at night!
33
12 month WCC
- development
- AG
- Plans/orders
```
Development
o Uses cup
o 1-3 words other than mama or dad
o Walks alone or with hand held
o Claps, waves
o Comes when called
o Pincer grip
```
```
Anticipatory Guidance
o Encourage variety of food
o Daily dental care
o Car seat
o Reinforce poison control
o Whole cows milk: 16-24 oz per 24 hours (for brain development!!)
o Encourage autonomy but set limits
o Wean from bottle by 12 mo
```
Plans/Orders
o Peds Response form: ask parents about things the are worried about, often topics already covered but can come up with other issues too
34
15 month WCC
- development
- AG
```
Development
o Walks well
o Drinks from cup
o Points to indicate words
o Vocab 3-6 words
o Crawls up stairs
o Stoops and recovers
o Plays ball
o Scribbles
```
Anticipatory Guidance
o No more bottle
o Start using utensils, won’t be good until 18-24 months
o Toddler appetite slump: 15 month to 2 years, mostly due to decreased growth rate
o Sit down to eat, not allowed to walk around house with food
o Encourage healthy diet
o Poison
35
18 month WCC
- development
- AG
- Plans/orders
```
Development
o Pacifier only during naps and at night (should totally wean no later than age 4)
o Self-feeding
o 7-20 vocab words
o Understands simple commands
o Walks up stairs
o Combines two words
o Removes clothes
o Knows 1 body part
```
```
Anticipatory Guidance
o Takes hand when crossing street
o Toilet training readiness (signs ready: 1. Able to pull pants up and down 2. Unhappy to be wet or dry 3. Can hold urine: wake up from nap or night dry)
o Brush teeth
o Proper snacks
o Fire safety, smoke alarm, car seat
o No bottle
o Daycare
o Biting/thumb sucking/pacifier
o If not in daycare, find a way to socialize
```
Plans/Orders
o M-CHAT to screen for autism
36
2 year WCC
- development
- AG
```
Development
o Washes hands
o Imitates household tasks
o Scribbles, can draw a circle
o Cups/spoon well
o 50+ words
o 2 word phrases
o Kicks/throws ball
o Opens door
o Climbs stairs
```
```
Anticipatory Guidance
o Car seat
o Play supervision
o Toilet training
o Dental hygiene
o Sleep in own bed
o Healthy diet
o Reading – super important!!
o Interactive play
```
37
Tantrums
* Reassure is normal
* Find out what is causing it, usually bc frustrated don’t ‘have the skills to do something OR want to do something that is denied d/t safety concern.
38
3-4 year WCC
- development
- AG
```
Development
o Puts on some clothing
o Pedals tricycle
o Uses plurals
o Daytime toilet trained
o Speech usually intelligible by strangers
o Walks a few steps on tip toe
o Counts to ____
o Knows some colors
o Concept of one
o READING
o Jumps in place, forward
o Knows name/age/sex
```
```
Anticipatory Guidance
o TV <2 hours a day
o Preschool/daycare
o Traffic safety
o First dental visit at 3
o Offering choices makes discipline easier
o Naps/bedtime routine
```
39
3-4 year WCC
- development
- AG
Development
o Ensure ready for school: Parent’s checklist for school entry and after (best about age 4, most should be checked if child is ready for school)
o Gesell Test – draw figures (circle, cross, square, etc.)
```
Anticipatory Guidance
o Bike safety, swim lessons
o Adult seat belts if not in booster
o Dental care
o Address and phone number
o Diet
o Home fire plan
o Stranger awareness
o Reading/library card
```
40
Early elementary school (6-8) WCC
- development
- AG
- plans/orders
Development
o Pediatric symptom checklist: picks up lots of school issues such as anxiety, ADHD clues, learning disability clues. Higher score associated with more problems in school
o Quick reading assessment
```
Anticipatory Guidance
o Safety: bike, skateboard, etc
o Seatbelt use
o Swim lessons
o Exercise
o Limit TV
o Healthy diet
o Dental care
```
Plans / Orders
o Vision
o Hearing
41
Later school age WCC
- Stop doing development questions about age 12
| - Instead do questionnaire to screen for eating disorders, depression, and alcohol/substance abuse
42
Teething information
- Fever above >101 NOT caused by teething
- 3-4 months all babies chew, drool, and slobber, prob not teething
- Average first tooth is 7-9 months
- Most 1 yo will have 4 bottom and 4 top teeth
- Molars 12-18 months
- Canines about 18 months
- 2 year molars around 2.5
- Lots of variation!
- First lost tooth between 5-8, if got teeth early will prob loose teeth early
Pediatrics 2
flashcards
Decks in class (7)
# Cards
