Pediatrics 02: Infant female well-child visits (2, 6, and 9 months) User: Alexander Chacon Ardite Email: firstname.lastname@example.org Date: October 9, 2020 2:59AM
Recognize appropriate growth patterns in infants up to 9 months of age using standard growth charts. 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. Explain the difference between developmental surveillance and developmental screening. List normal developmental milestones at 2, 4 and 6 months. Discuss the importance of prevention and anticipatory guidance during the well visits, including behavior, development, safety and immunizations. Develop a differential diagnosis for an asymptomatic abdominal mass in an infant; formulate a plan for evaluation.
Components of a Well-child Visit
Ask if there have been any illnesses or problems since the previous visit. If this is the first visit, obtain a detailed birth history. Using the available medical records, review any visit notes, hospitalizations, lab results, and radiology reports since the last visit.
May be assessed using one of several developmental screening tests (e.g., the Parents’ Evaluation of Developmental Status [PEDS], or Ages and Stages Questionnaire [ASQ]). The American Academy of Pediatrics (AAP) recommends developmental screening with a validated tool at the 9-month, 18- month, and 30-month checkups. Specific autism screening is recommended at the 18-month and 24-month visits. Developmental surveillance is recommended at every health maintenance visit where a validated developmental screening tool is not used. Tests may involve parental reports and/or examination in the office.
Growth is best assessed using a growth chart and analyzing the data over time. Diet History
Inquire about feeding practices: breast or bottle (in infants), or types and frequency of food and drink (in older children), and any feeding difficulties the parent has noted.
Obtaining a family health history is an important component of the well- child visit that can provide information on genetic, behavioral, and environmental vulnerabilities. A family health history should be obtained at the initial visit and updated yearly.
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 risks (e.g., smokers, guns in the home, lead exposure). Mothers should be screened for postpartum depression during infant well-child visits. Given the peak times for postpartum depression, the American Academy of Pediatrics recommends integrating screening with the Edinburgh Postnatal Depression Scale at the 1-,2-,4-, and 6-month visits.
Each visit includes anticipatory guidance, which is your chance to help the parents anticipate the child’s development and nutritional needs and to advise them regarding the child’s safety.
Immunizations and lab work
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Age-specific recommended immunizations and screening labs are performed at the conclusion of the visit.
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.
Commercial formulas provide complete nutrition for those babies whose mothers are unable or unwilling to breastfeed. Available formulas include those made with:
Cow’s milk protein Soy protein, or Hydrolyzed cow’s 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: Baby is fed directly from the bottle Powder: Two scoops of the powder are mixed with 4 oz water Formula concentrate: 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 Cow’s Milk
Infants should take breast milk or formula until 12 months of age. According to the American Academy of Pediatrics: Young infants cannot digest cow’s milk as completely or easily as they digest breast milk or formula. Cow’s milk contains high concentrations of protein and minerals, which can stress a newborn’s immature kidneys. Cow’s milk lacks iron, vitamin C, and other nutrients that infants need. Cow’s milk can irritate the lining of the stomach and intestine, leading to blood loss in the stool. Cow’s milk does not contain the optimal types of fat for growing infants.
Most babies lose a little weight right after birth, then may regain their birth weight as early as 1 week of age, but are definitely 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.
This reflex is elicited by an abrupt change in the infant’s 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.
Developmental Surveillance and Screening
Evaluating a child’s development may 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
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Checking milestones (comparing a child’s 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 24 months of age. For more information on developmental screening, see the AAP’s Policy Statement and Aquifer’s 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
Babies are developmentally ready to begin spoon feeding 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 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 or milk a day (both of which are 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. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162938 Accessed March 15, 2018. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162938. Accessed March 15, 2018. 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 SIDS, 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
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 age 2 years, children should face rearward. The National Safety Transportation Board and the AAP stress that the back seat is the safest place in a vehicle for children. 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
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These are the vaccines and the number of doses of each that children should receive through 6 years of age:
Vaccine Immunizes Against Number of Doses
DTaP Diphtheria, tetanus, pertussis 5
IPV Polio 4
Hib Haemophilus influenzae type B 3 or 4, depending on the vaccinemanufacturer
PCV13 Pneumococcus (13 strains) 4
MMR Measles, mumps, rubella 2
Varicella Varicella 2
RotaV Rotavirus 2 or 3, depending on the vaccinemanufacturer
HepA Hepatitis A 2
HepB Hepatitis B 3
(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 patient’s 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 CDC’s 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.
The Red Reflex
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
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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.
6-Month Developmental Milestones
Rolls over supine to prone
Sits briefly unsupported
No head lag when pulled to sit from supine
Reaches for objects and transfers
Looks for dropped itemss
Bangs small object on surface
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.)
Social/Adaptive Feeds self/pats r smiles at reflection
Demonstrates stranger recognition, the prelude to stranger anxiety
Toddler-Proofing the Home
There are several steps parents or guardians should take to childproof their home – before children begin crawling and walking. These include:
Installing outlet covers Putting in cabinet locks Setting up stair barriers and Making sure cleaning supplies and medicines are safely stored.
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. 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. Babies do not need juice. To prevent choking, all solid foods should be soft and easy to swallow.
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 AAP’s 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
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year’s immunization requirements are available from the CDC.
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) 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.
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
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:
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.
Weight and Length
Review the weight and length as recorded, repeating any measurement that is concerning or seems inconsistent. 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.
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.
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When the family is emotionally ready to hear more information, it is important to convey that treatment decisions need to be made urgently.
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.
A chest x-ray can identify metastases to the chest. Chest CT or MRI is necessary only if metastases are seen on x-ray.
A skeletal survey can identify metastases to the bone. Abdominal Ultrasound
An abdominal ultrasound will identify a mass, show the organ of origin, and determine if the mass is solid, cystic or combined. (Purely cystic masses are less likely to be malignant.) This is the best choice for a first imaging study.
A plain film can identify the presence of a mass, and perhaps whether it has calcifications, it cannot reveal other important information about the mass. This film may be more urgent if there is any evidence of bowel obstruction from the mass. The plain radiograph is not the best imaging study to order first.
A CT is best at revealing calcifications, and-importantly especially for a surgeon-shows the anatomy better than an ultrasound. It also reveals the consistency of the tumor. Allows evaluation of the lungs during the same study, which is important in finding metastases. If a lesion is purely cystic, a CT scan is not needed, which is why an ultrasound is done first.
Differential Diagnosis for RUQ Mass and Pallor in a 9-Month-Old Infant
Serious illnesses may cause a decrease in growth and even weight loss, but normal growth should not eliminate serious diagnoses from your differential.
Although rare in children this age, an hepatic neoplasm (whether malignant, such as hepatoblastoma, or benign) can cause an asymptomatic abdominal tumor and must be considered in a young infant with an asymptomatic RUQ abdominal mass.
Jaundice may be a feature, but the lack of jaundice does not rule out this diagnosis.
An obstruction at the uretero-pelvic junction can lead to hydronephrosis and a palpable kidney, sometimes manifesting as a flank mass.
In the newborn, a multicystic kidney may cause such an obstruction.
While possibly asymptomatic, hydronephrosis causing a 6 cm palpable mass would usually present with a urinary tract infection.
The most frequently diagnosed neoplasm in infants; more than half of patients present before age 2.
The tumor may present as a painless mass in the neck, chest, or abdomen.
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Neuroblastoma Children with an abdominal neuroblastoma may be asymptomatic; however, they may also appear chronically ill and may have bone pain from metastases to the bone marrow or skeleton.
Fever, pallor, and weight loss are frequent presenting symptoms.
Neuroblastoma is a likely diagnosis in an infant younger than a year of age who has an asymptomatic RUQ abdominal mass and pallor and no jaundice.
This is a rare malignant tumor.
A teratoma may present as a painless abdominal mass without other symptoms or it may cause pressure effects on neighboring structures resulting in abdominal or back pain, nausea, vomiting, constipation, and/or urinary tract symptoms.
A rare form of cancer (which in itself is rare in children), teratoma should be considered, even if it is quite low on the list.
Wilms’ tumor (nephroblastoma)
This is a likely diagnosis in a child with an asymptomatic RUQ abdominal mass who has no lymphadenopathy or jaundice on exam and who is growing and developing normally.
These tumors are often discovered by the parents or on routine examination.
The masses are generally smooth and rarely cross the midline.
Associated symptoms occur in 50% of patients and include abdominal pain and/or vomiting; patients may also be hypertensive.
The median age at diagnosis is 3 years.
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