Pediatrics

APGAR Scoring

• Notes:
• • Insert nasal catheter and observe reflex irritability.
  • APGAR is taken at 1 and 5 min, and again at 10 and 20 min in compromised infant.
  • Record lost points (eg. 1min APGAR=9, -1 for color)

Developmental Milestones

G: Gross Motor, F: Fine Motor, L: Language, S: Social

• Age: 1mo
  • G: Raises head from prone
  • F: Tight grasp, follows to midline
  • L: Alerts to sound (startle)
  • S: Regards face
• Age: 2mo
  • G: Lifts head 45deg from prone; lifts chest
  • F: Follows past mid-line
  • L: Social smile
  • S: Recognizes parent
• Age: 3mo
  • G: Support on fore arms; steady head control
  • F: Holds hands open at rest, follows 180deg
  • L: Coos, vocalizes
  • S: Reaches for familiar people/objects; anticipates feeds
• Age: 4-5mo
  • G: Rolls front to back, begins to sit when propped, supports on wrists & shifts weight
  • F: Hands to midline, grasps rattle, touches cube on table
  • L: Orients to voice at 5mo; orients to bell laterally, says “ah-goo”, razzes
  • S: Enjoys looking at environment
• Age: 6-8mo
  • G: Sits alone, rolls both ways, bears weight
  • F: Reaches with either hand, transfers hand to hand, raking, grasp
  • L: Babbles, laughs; at 7mo, orients to bell diagonally; at 8mo, “dada/mama” indiscriminately
  • S: Stranger anxiety
• Age: 9-11mo
  • G: Creeps, crawls, pulls to stand, cruises, pivots when sitting
  • F: Pincer grasp, probes/pokes with forefinger, holds bottle
  • L: Understands “no” & name, waves bye-bye; at 10mo, “dada/mama” indiscriminately; at 11mo, one word
    S: Plays pat-a-cake, peek-a-boo; explores environment
• Age: 12-14mo
  • G: Walks alone
  • F: Throws objects, lets go of toys, mature pincer grasp, points
  • L: Follows 1-step command with gesture, 2 words; at 14mo, 3 words
  • S: Imitates actions, comes when called
• Age: 15-17mo
  • G: Crawls upstairs, walks backwards, stoops to recover object
  • F: 2-block tower, scribbles, finds hidden toy, inserts raisin into bottle
  • L: 1-step command without gesture, points to 1-2 body parts, 4-6 words, immature jargoning
  • S: Indicates wants without crying
• Age: 18-20mo
  • G: Runs, kicks/throws ball, sits in chair, walks upstairs with one hand held
  • F: 3-4 block tower, turns 2-3 pages at a time, spoon feeds self, dumps raisin from bottle
  • L: 7-20 words, mature jargoning
  • S: Copies parents at household tasks, plays with other children
• Age: 21-23mo
  • G: Goes upstairs, squats in play
  • F: 5-block tower, drinks from cup
  • L: Points to 3 body parts
  • S: Asks to have good and go to toilet
• Age: 24mo
  • G: Up & downstairs, jumps
  • F: Turns pages one at a time, remove shoes, pants, imitates stroke (writing)
  • L: 50 words, 2-word sentences, uses pronouns, points to 5 body parts, follows 2-step commands
  • S: parallel play, asks questions
• Age: 30mo
  • G: Jumps with both feet off floor, throws ball overhand
  • F: Unbuttons, holds pencil in adult fashion
  • L: Repeats 2 digits, understands concept of “1”
  • S: Tells 1st & last name when asked, gets self a drink
• Age: 3yr
  • G: Pedals tricycle, alternates feet going up steps, stands briefly on one foot
  • F: 9-block tower, imitates bridge or 3 cubes, draws a circle
  • L: 3-word sentences; uses plurals, past tense, 250 words, understands concept of “2”
  • S: Group play, shares toys, takes turns; knows full name, age, and sex
• Age: 4yr
  • G: Hops, skips, rides tricycle, climbs ladder, alternates feet going down stairs
  • F: 10-cube tower, catches ball, can cut & paste, draws cross, person with face, arms, body and legs
  • L: Knows 3-4 colors, counts to 10, says song or poem from memory
  • S: Tells “tall tales”, dresses with supervision
• Age: 5yr
  • G: Walks on tiptoes, jumps over obstacle
  • F: Ties shoes, uses a knife to spread, and draws triangle, prints 1st name
  • L: Knows colors, defines 1 word, and identifies coins
  • S: Plays competitive games, abides by rules, sexual curiosity, dresses alone
• Age: 6yr
  • G: Rides bicycle
  • F: Draws person with 6 body parts
  • L: Knows right from left
• Age: 8yr
  • F: Draws diamond
  • L: Tells time, reads for pleasure
  • S: Sense of humor, home chores

Developmental Delay

• DQ=Developmental score/Chronological age x 100
• If <80 (1 standard deviation) do work-up
• Most common causes of developmental delay:
  • 1. Mental Retardation
  • 2. Autism
  • 3. Psychosocial
  • 4. Hearing loss
  • 5. Expressive/receptive language disorder
  • 6. Selective mutism

Fluids and Dehydration

• Assessment of Hydration Status
  • 1. Parent estimate of intake: fluid type (water, formula, juice, etc…) and amount retained
  • 2. Parent estimate of output: urine, stool, vomit, drainage, insensible losses (# of diaper changes now vs. usual, consistency of stool)
  • 3. Physical signs (% Dehydrated)
  • Skin Turgor: good (5%), good/slight tenting (10%), tented (15%)
  • Mucous Membranes: moist (5%), tacky (10%), dry (15%)
  • Eyes: normal (5%), deep set (10%), sunken (15%)
  • Fontanelle: flat (5%), soft (15%), sunken (15%)
  • Mental Status: consolable (5%), irritable (10%), lethargic/coma (15%)
  • Cardiovascular: normal (5%), tachy, normal BP (10%), decreased BP, poor capillary refill (15%)
  • Urine/tears: concentrated urine, poor tear production (5%), oliguria, poor tear production (10%), oliguria/anuria, no tears (15%)
  • Note: dehydration estimated from % wt loss from premorbid state
• Treatment:
  • Initial Bolus
  • Give a bolus of isotonic (NS or Lac Ringer’s) to rapidly re-expand the intravascular volume.
  • Assess response (Urine output, capillary refill, vital signs, mental status, etc…).
  • Repeat bolus if necessary.
  • 10cc/kg over 1hr for mild dehydration (5%)
  • 20cc/kg over 1hr for moderate dehydration (10%)
  • 30-50cc/kg over 1hr for severe dehydration/shock (15%)
• Rehydration
  • – Add fluid deficit to maintenance; give half of total volume in 1st 8hr and the rest over 16hr.
  • – Fluid Deficit (cc) = est. % dehydration x wt. (gm); ignore initial bolus in calculation
  • – Maintenance Fluid
  • – Based on wt:
  • – 100cc/kg (4cc/kg/hr) for each of the 1st 10kg
  • – 50cc/kg (2cc/kg/hr) for each of 2nd 10kg
  • – 20cc/kg (1cc/kg/hr) for each additional kg
  • Based on surface area (wt>10kg):
  • 1500-1800cc/m2/d x surface area (m2)
  • <20kg/m2 = [(3.6 x wt)+9]/100
  • >20kg/m2 = [(2.5 x wt)+9]/100
  • Require 3mEq Na/100cc, 2mEq Cl/100cc, 2mEq K/100cc
  • (D51/4NS in small children and D51/2NS in older children with 20mEq KCl after 1st void.)
  • Replace ongoing losses (stool, NG tube, etc…) cc for cc.
  • Note: above schema is only a guideline; continually reassess and adjust management to needs.

Growth Progression

• Weight:
  • Neonates lose 5-10% of birth weight in 1st few days of life
  • Birth weight regained by 7-10d, x2 by 4-5 mo, x3 by 1yo and x4 by 2yo
  • Daily gain is 20-30gm/d for 1st 3-4 mo, 15-20gm/d for rest of 1st yr; 5lbs/yr from 2yo to puberty
  • Avg. weight: 3.5kg at birth, 10kg at 1yo, 20kg at 5yo, 30kg at 10yo
• Height:
  • Avg. length: 20in at birth, 30in at 1yo, 3ft at 3yo, 40in at 4yr (x2 birth length)
  • Avg. gain: 2-3in/yr from 4yo to puberty
• Head Circumference (H/C):
  • Avg. H/C at birth 34cm, at 2yo 48cm
  • Avg. gain: 2cm/mo for 1st 3mo (40cm by 3mo), 1cm/mo for next 3mo (43cm by 6mo), 0.5cm/mo for
  • rest of 1st yr (46cm by 1yo); 10cm over rest of life

Immunization Timeline

• Birth:
  • Hepatitis B (HBV)
• 2 Mo:
  • Diphtheria, pertussis, tetanus (DTP), oral poliovirus (OPV), Hib Conjugate (hemophilus influenza, type B), HBV
• 4 Mo:
  • DTP, OPV, Hib Cong
• 6 Mo:
  • DTP, Hib Conj, HBV
• 12 Mo:
  • MMR, PPD
• 15-18 Mo:
  • Diptheria, tetanus, acellular pertussis (DtaP), OPV, Hib Conj
• 4-6 Yr:
  • DtaP, OPV, MMR
• 14-16 Yr:
  • Tetanus-adult dose, diptheria-reduced dose, every 10yrs (Td)
• For Children Behind in Immunizations (over 1yr old):
  • If < 7yo:
    • DTP, OPV at first visit and then 2, 4, and 10mo later
    • MMR at first visit if >12-15mo, or when becomes 12-15 mo
    • Hib at first visit if >15mo and < 5yo (if <15mo, Hib conj has a special catch-up schedule)
    • DTaP and MMR at 4-6yo and Td at 14-16yo; repeat Td every 10yrs.
  • If >7yo:
    • Td, OPV, MR at first visit (2nd MMR at any time at least 1 mo after 1st).
    • Td and OPV #2 10mo later
    • Td at 14-16yo; Repeat Td every 10 years.
    • Note: Live virus vaccines (OPV, MMR) are contraindicated in immunocompromised children, in children who have immunocompromised people in their household, and in pregnancy.

Infant Diet Guide

• 1st 4-6mo of life:
  • Breast milk or formula; water (helps with constipation)
  • Supplement with vitamin D (if breast fed), fluoride (if not in water)
• Premies:
  • multivitamin, Fe, +/- folate and fluoride
  • Require 100-120kcal/kg/d
• After 4-6mo:
  • Start solids (preferably after 6mo) and decrease breast/bottle feeds to <32oz/d; may need to increase water (higher renal solute load)
  • Start 1 new single ingredient food at a time, new foods only q3-4d. Cereal (rice, oatmeal, barley);
  • Fruit (banana); Vegetables (orange before green); juices (0.5 adult juice, 0.5 water).
  • DO NOT give eggs, citrus, desserts, or whole cow’s milk (can lead to allergies)
  • Decrease breast/bottle feeds as increase solids.
  • Decrease breast/bottle feeds to <24oz/d when teething and DO NOT leave bottle in crib (“milkbottle caries).

Primitive Reflexes

• Reflex: Duration
• Palmar (hand) grasp: Birth to 4mo
• Plantar (foot) grasp: Birth to 9mo
• Automatic stepping: Birth to 2mo
• Moro: Birth to 3-6mo
  • (tested by supporting the baby’s head in supine position, then suddenly dropping it 2-3in while supporting)
• Head in space: 1-2mo/permanent
  • (hold baby upright in air and tilt slightly to side; observe if it can hold head vertically (reflex present)
• Asymmetric tonic neck (ATNR): Birth-1mo to 4mo
  • (Turning head to one side causes ipsilateral arm to extend and contralateral arm to flex)
• Symmetric tonic neck (STNR): 5-6mo to 8mo
  • (Extending the head causes hips and knees to flex, while flexing causes hips and knees to extend)
• Landau: 3mo to 12-24mo
  • (Hold the trunk in prone position and while in the air, look for arm, leg and head extension)
• Parachute-downwards: 3-4mo/permanent
• Parachute-sideways: 6mo/permanent
• Parachute-forwards: 7-8mo/permanent
• Parachute-backwards: 9-10mo/permanent
  • (Parachute reflexes are protective to sudden disruptions of balance; leg extension for downwards, arms out for others. The baby must have good head control (around 4mo old) to test.

Tanner Stages of Pubertal Development

• Breast development:
  • Stage B1: prepubertal, elevation of the papilla only.
  • Stage B2: breast buds visible or palpable with enlargement of the areola.
  • Stage B3: further enlargement of the breast and areola with no separation of their contours
  • Stage B4: projection of areola and papilla to form a secondary mound over the rest of the breast.
  • Stage B5: mature breast with projection of papilla only.
• Male genital development
  • Stage G1: prepubertal.
  • Stage G2: enlargement of testis to more than 2.5 cm, appearance of scrotal reddening, and increase in rugations.
  • Stage G3: increase in length and to a lesser extent breadth of penis with further growth of testis.
  • Stage G4: further increase in size of penis and testes and darkening of scrotal skin.
  • Stages G5 and G6: adult genitalia.
• Pubic hair growth among boys
  • Stage P1: preadolescent, no pubic hair.
  • Stage P2: sparse growth of slightly pigmented, slightly curved pubic hair mainly at the base of the penis.
  • Stage P3: thicker curlier hair spread laterally.
  • Stage P4: adult-type hair that does not yet spread to medial thighs.
  • Stage P5 adult-type hair spread to medial thighs.
• Appearance of pubic and labial hair among girls
  • Stage PH1: prepubertal, no pubic hair.
  • Stage PH2: sparse growth of long, straight, or slightly curly minimally pigmented hair, mainly on labia.
  • Stage PH3: considerably darker and coarser hair spreading over mons pubis.
  • Stage PH4: thick adult-type hair that does not yet spread to the medial surface of the thighs.
  • Stage PH5: hair is adult type; distributed in the classic inverse triangle.
• Females:
  • Thelarche (breast buds) 1st sign of puberty at about 11yo, followed by adrenarche (pubic hair).
  • About 1yr after thelarche at Tanner 3, peak growth spurt occurs.
  • About 6mo after growth spurt at Tanner 4, menarche occurs.
  • Breast development from Tanner 2-5 takes 4yrs on avg. and pubic hair development takes 2.5yrs.
• Males:
  • Testicular growth at about 11.5yrs is 1st puberty sign, marking Tanner 2.
  • Pubic hair appears next with penile enlargement within 1yr of testicular enlargement.
  • Progression to Tanner 5 over 3yrs, with growth spurt in Tanner 4-5.

Teeth Eruption

• Central Incisors
• • Primary: U 5-7mo, L 6-8mo
  • Permanent: U 7-8yr, L 6-7yr
• Lateral Incisors
  • Primary: U 8-10mo, L 6-8mo
  • Permanent: U 8-9yr, L 7-8yr
• Cuspids:
  • Primary: U 16-18mo, L 14-18mo
  • Permanent: U 11-12yr, L 9-10yr
• First Bicuspids:
  • Permanent: U 10-11yr, L 10-12yr
• Second Bicuspids:
  • Permanent: U 10-12yr, L 11-13yr
• 1st Molars:
  • Primary: U 12-16mo, L 10-14mo
  • Permanent: U 6-7yr, L 6-7yr
• 2nd Molars:
  • Primary: U 22-26mo, L 18-22mo
  • Permanent: U 12-13yr, L 12-13yr
• 3rd Molars (wisdom):
  • Permanent: U 17-22yr, L 17-22yr

(U: Upper, L: Lower)