APGAR Scoring

(skin color)
Blue, paleBody pink,
Extremities blue
PulseAbsent< 100 bpm> 100 bpm
(reflex irritability)
FlaccidSome flexion of
Active motion
(sneeze, cough,
pull away)
(muscle tone)
AbsentArms and legs
Vigorous cry
Severely depressed 0-3
Moderately depressed 4-6
Excellent condition 7-10
  • 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)