Introduction to Pediatrics and Neonatology

Father of pediatrics: Abraham Jacoby

Pediatrics is a science about the healthy and sick child.

It is the branch of medicine that deals with the medical care of

1. Infants
2. Children 
3. Adolescents 

The age limit usually ranges from birth till 18

 

DIFFERENCES BETWEEN ADULT AND PEDIATRIC MEDICINE

1. Body size differences maturation differences in adults. 
2. Congenital defects, genetic variance and developmental issues are great in children
3. Pediatrics involves treatment of both the child a parents (even whole family) 

WORK STYLES

1. Independence
2. Self control
3. Adaptability / flexibility in loca
4. Cooperation

TASKS

1. Examine patients or order, perform and interpret diagnostic tests to obtain info on medical condition and determine diagnosis. 
2. Advise patients, parents and community members concerning diet,  activity, hygiene and disease prevention 
3. Explain procedures and discuss test results or prescribed treatments with patients a parents guardians
4. Monitor patients condition, progress and reevaluate treatments as necessary. 
5. Plan and execute medical care programs to aid in the mental and physical growth a development of children & adolescents. 
6. Direct and coordinate the activities of nurses, students, assistants, Specialists, therapists & other medical staff.

 

HEALTH INDICES 

1. General birth rate of the population (%) = (The number of people born alive during 1 year x 1000)/Mid-annual population
2. General mortality rate of the population (%) = (The number of people who died during 1 year x 1000)/Mid-annual population
3. Infant mortality rate (%) = (The number of infants born dead under the  age of l year x 1000)/Common no of infants born alive for a year
4. Neonatal mortality rate (%) = (Number of infants born alive and died on the 1st month of life x 1000)/Common no of infants born alive during 1 year
5. Early neonatal mortality rate (%) = (No of infants born alive and have died in the 1st 6 days x 1000)/Common number of infants born alive during one year
6. Still birth rate (%) = (Number of infants born dead after 28 weeks of pregnancy x 1000)/ Number of infants born alive a dead during one year

* These are demographic indices

 

 

NEWBORN CHILD, PECULIARITIES OF NEWBORN PERIOD

Neonatology –   Branch of pediatrics that deals with diseases and the care 2 of newborns.

Neonatal Period – Period from birth to the 28th day of life (term after birth).

Perinatal Period – Period from the 28th completed week of gestation to the 7th day after birth.

CLASSIFICATION OF NEONATES

• By birth weight (BW)
• By gestational age (GA)
• By both BW & GA

CLASSIFICATION BY GESTATIONAL AGE 

1. Full term infant. – An infant born @ a gestational age between 37 and 42 completed weeks
2. Pre-term infant – An infant born prior to 3 weeks of gestation (22 – 37 weeks or weight greater than 500 g)
3. Post term infant – An infant born after the 42nd week of gestation

ACCORDING TO RELATIONSHIP BETWEEN GA AND BW

1.  AGA (Appropriate for Gestational Age) – Infants with birth weight for their gestation age that falls – between the 10th & 90th percentiles.
2. SGA (Small for Gestational Age) – Infants with birth weight for their gestational age that falls below the both percentiles.
3. LGA charge for Gestational Age) – Infants with birth weight for gestational age that falls above the 90th percentile.)

 

THE APGAR SCORE

• This is the very first test given to a newborn
• It occurs in the delivery room right after the birth of the baby
• The test was designed to quickly evaluate a newborn’s physical condition & to see if there is an immediate need for extra medical or emergency care.

PURPOSE

1. Evaluate the conditions of the baby@ birth
2. Deferring the need for resuscitation
3. Evaluate effectiveness of resuscitation efforts
4. Identify neonates @ risk for morbidity a mortality

0-3 – critically low 

4-6 – fairly low . 

7-3. gen. Normal

• Perfect score for each category is 2
• multiply by 2 to get the overall score

ROLE IN EVALUATION

• The APGAR score was developed in 1952 by an anesthesiologist named Virginia Apgar.
•  It is also an acronym for:
  • Appearance (skin color)
  • Pulse (Heart rate)
  • Grimace (Reflex irritability response to catheter in nostril)
  • Activity (muscle tone)
  • Respiration ( Breathing rate & effort)
• It is used to evaluate
  • brain function @ birth
  • Circulatory status @ birth
  • Effectiveness of respiratory & circulatory adaptation thereafter.
  •  Which babies need active assistance (resuscitation),

SIGNIFICANCE OF APGAR SCORE

1. Healthy newborn 7-10 @ both 1 and 5 minutes
2. Moderately depressed newborn 3-6 (Need resuscitation)
3. Severely depressed newborn 1 – 3 (Intensive resuscitation)

 

ANTHROPOCENTRIC MEASUREMENTS

WEIGHT 

• Average newborn weight = 3200 – 3400 g (3.2-3.4 kg)
• range = 25009 to 40009
• Physiologic weight loss It is normal for the newborn infant to look 5-10% or (6-8%) of weight in the 1st 4 to 5 days of life.
•  Causes
  • Low nutritional intake
  • Defecation
  • Urination.

Weight monitoring

Age of Infant	Monthly Gain(g)	Gains on whole period(g)
1	600	600
2	800	1400
3	800	2200
4	750	2950
5	700	3650
6	650	4300
7	600	4900
8	550	5450
9	500	5950
10	450	6400
11	400	6800
12	350	7150

“n” is weight in kg

• 2-10 Years w = 10 + 2n
• 10 – 16 years w= 30 + 4(n-10) or w= 2n + 8
• Yearly gain = 2 kg
• Puberty spurt = 4 kg

LENGTH / HEIGHT

• Recumbent Height/Length (below 12 months)
  • Measured in Supine position
  • Head in mid line
  • Pinna of the ear on the imaginary vertical line with the lower eyelid of the eye
  • Measured from head to heel

Age in months	Monthly Gain	Gain of whole period
1	3	3
2	3	6
3	3	9
4	2.5	11.5
5	2.5	14
6	2.5	16.5
7	2	18.5
8	2	2.05
9	2	22.5
10	1-1.5	23.5-24
11	1-1.5	24.5-25
12	1-1.5	25.5-26

• 
  Standing Height/Length (above 12 months)
  • Back straight
  • Head in mid line
  • Horizontal line imaginary
• 1 – 4  years H = 100 – 8( 4 – n )
• 5 – 15 years H = 100 + 6( n – 4 )or H = 6n + 80
• Yearly gain = 8 cm (1 – 4 yrs) and 6 cm after
• Puberty spurt =16 cm (female) 20 cm (male)

 

HEAD CIRCUMFERENCE.

Head circumference @ birth = 34 – 36 cm or (33 – 55 cm)

It is 2-3 cm larger than chest circumference

Birth to 6 months

HC = 43 – 115(6-n)

6 to 12 months

HC = 43 + 0.5(n-6)

1 to 5 years

HC =50-1(5-n)

5 to 15 years

HC=50 + 0.6 (n-5)

 

Head Circumference monitoring

Age	GNN
Birth to 6 months	1.5 cm (monthly gain)
6 to 12 months	0.5 cm (monthly gain)
1 to 5 yrs	1 cm (yearly gain)
6 to 15 yrs	0.6 cm (yearly gain)

CHEST CIRCUMFERENCE

Chest circumference @ birth = 32 – 34 cm or (30 – 33 cm)

O to 6 months

Chc = 45-2 (6-n).

6 to 12 months

Chc – 45 + 0.5 (n-6)

1 to 10 years

Chc= 63 – 1.5 (10-n)

10 to 15 years

Chc = 63+ 3 (n-10)

Chest Circumference monitoring

Age	Gain
Birth to 6 months	2 cm (monthly gain)
6 to 12 months	0.5 cm (monthly gain)
1 to 10 yrs	1.5 cm (yearly gain)
11 to 15 yrs	3 cm (yearly gain)

 

PERCENTILES

1. Mean normal growth = 25-75-90 i
2. Mean less than average data= 10-252
3. mean greater than average data = 75-90
4. Mean low data = 3-10
5. Mean high data = 90-97
6. Mean extremely low data = Below 3
7. Mean extremely high data = Above 97

Extra high = above 97

High = 90=97

Greater average = 75-90

Normal = 25-75

Less than average = 10-25

Low = 3-10

Extra Low = Below 3

 

FONTANELS

ANTERIOR FONTANEL

• Located @ the intersection of the sutures of the 2 parietal bones and the frontal bones.
• it is diamond shaped
• It is about 2 to 4 cm
• It closes in about 12 to 18 months ago
• It measures about 4 cm in its antero-posterior and 2.5 cm in its transverse diameter.

POSTERIOR FONTANEL

• Located between the sutures of the 2 parietal bones and the occipital bone.
• It is small and triangular in shape
• It normally closes at 1.5 to 3 months of age.

RESPIRATORY SYSTEM 

Fetal Lung Development

• Filled with fluid
• Surfactant synthesis begins @ 24 to 28 weeks & peaks @ 35 weeks.

Establishment of breathing after birth

• Opening of alveoli by mechanical, chemical, thermal or sensory stimuli

Characteristics of Newborn Respiration

• Normal RR = 30 to 60/min (av = 40 / min)
• It is shallow and irregular
• There are 5 to 15 secs of apnea.

APNEA 

• No breathing for periods greater than 15 s.

Abnormal findings

• Retractions
• Granting
• Nasal flaring
• More than 15 sec apnea
• Abnormal breathing rate

Circulatory System

Heart rate

• Ranges from 140 to 160 /min (100 when sleeping, 160 when crying)

Heart murmur

• Transient murmurs may result from the incomplete closure of the fetal circulation (ductus arteriosus / foramen ovale)
• 90% of all murmurs are transient & not association with anomalies.

Blood Pressure (@ birth)

• from 46 to 80 mm Hg (systolic) or 60-80
• 40 to 50 mm Hg (diastolic)
• Average 75/42 mm Hg

HEMATOLOGICAL System

Blood

• RBC = 4.8 – 7.1 (high )
• Heamoglobin  = 14 – 24 (high)
• Heamatocrit = 44 – 64 (high)
• WBC = o @ birth ; 23 – 25,000 @ day 1 with rel, neutrophilia.

* After the 1st few days (5 days or so) the white cell count is likely to be below 10 000 /mm3 with rel. lymphocytosis

of infancy & early childhood.

 Coagulation

• Vitamin K dependent clotting factors are decreased.

Platelet count

• (150,000 – 350,000) normal

Gastrointestinal Tract(GIT) 

• Sucking becomes coordinated @ 32 weeks
• Little saliva until 3 months of age
• Stomach holds 60 – 90 ml
• Regurgitates easily because of an immature cardiac Sphincter In the stomach & esophagus
• Immature liver function may lead to lowered glucose and protein serum level.

ALIMENTARY SYSTEM

• AT BIRTH ( meconium ) – Stringy, tenacious & black tarry texture stool
  • INGESTION OF Colostrum / FORMULA (Gradual transition) – Few greenish stools to gradual yellow color
    • EARLY INFANCY – (stools of formula fed baby) Lemon yellow color, soft more frequent
    • EARLY INFANCY (stools of breastfed baby ) Yellow orange color

HEPATIC FUNCTION

• Liver produces substances essential for clotting of blood.
• Stores need iron in the 1st few months
  • Preterm and small infants have lower iron stores
  • Full term infants have more (their stores last 4-6 months)

Physiological Jaundice

• After 24-48 hrs of age jaundice occurs
• This is due to increased RBC breakdown & immature liver Exning.
• It is a yellow discoloration that may be seen in infants skin or in the sclera of the eyes
• It is caused by excessive ants of free bilirubin in the blood & tissue.

URINARY SYSTEM

•  GER is lower (about 1/4th to 1/2 of that in an adult)
• Kidneys not fully functional till child is about 2 yrs
• Urine often contains protein in small urates.
• Urine may contain an abundance of urates which may give the diaper a pink stain during the 1st wk of life.

 

KIDNEYS AND URINATION

• Initial urine is cloudy,  scanty in amount & uric acid crystals (reddish station diaper)
• 1st urination occurs within 24 hrs (ranges from 4-6 times /day in the 1st days & 20 X or more in later days of neonates
• Urine pH = 5 to 7
• Specific gravity = 1.006 to 1.020.

IMMUNE SYSTEM 

• limited specific a non-specific immunity @ birth
• Passive immunity from mother (IgG) for the 1st 3 months of life. (reduced if baby is born premature)
• Breastfeeding provides passive immunity (IgA)

 

NEUROMUSCULAR SYSTEM 

• Mature newborns demonstrate neuromuscular function by;
  • moving their extremities
  • Attempting to control head movement
  • Exhibiting a strong cry
  • Demonstrating newborn reflexes.

A newborn occasionally makes twitching or flailing movement of the extremities in the absence of stimulus because of the immature nervous system.

 

THERMO-REGULATION

NEWBORN Physiology

• Normal temp = 36.5 to 37.5°C
• Hypothermia = less than 36.5°c (significant contribution to deaths in Low birth weight infants a preterm newborns.
• Stabilization period = 1st 6 to 12 hours after birth

NEUTRAL Environmental Temperature

• The body temp is likely to be influenced by the environmental temp.
• The environmental temp. @ which the core temp of the infant @ rest is between 36.7 and 37.3 0c
• O2 consumption and caloric utilization are lowest @ this temp.

TEMPERATURE REGULATION 

• Newborn’s temp. may drop several degrees after delivery becouse the external environment is cooler than the intrauterine environmental.
• Rapid heat loss in a cool environment occurs by
  • Conduction
  • Convection
  • Radiation
  • Evaporation.

Cold stress in the newborn => Increase in metabolic rate => Increased O2 & demands a caloric consumption => metabolic acidosis 

 

SKIN

Common VARIATIONS

1. ACROCYANOSIS
   • Result of sluggish peripheral circulation
2. PHYSIOLOGICAL JAUNDICE
   • Neonatal jaundice is often seen in infants around the 2nd day after birth
   • It lasts until the 8th day in term births up to 14th day in premature births.
3. MILIA
   • All newborn sebaceous glands are immature.
   • white papule can be found on the cheek or across the bridge of the nose of every newborn.
   • It disappears by 2 to 4 weeks of age as sebaceous glands
   • mature and drain.
4. ERYTHEMA Toxicum
   • Erythematous macules & firm 1 – 3 cm yellow or white papules or Pustules
   • Pustules contain eosinophils & are sterile.
   • They appear in the 1st 3-4 days of life.
   • Range = birth to 14 days.
   • It is benign & self limited.
5. Lanugo
   • It is the fine hair, downy hair that covers a newborn’s shoulders, back or upper arm.
   • It may be found also on the forehead & ears.
   • A baby born after 37 to 39 weeks of gestation has more lanugo than a newborn of 40 weeks.
   • It disappears by 2 weeks of age,
6. VERNIX CASE OSA
   • At birth the infant is gen. covered with vernix caseosa
   • It is a cream cheesy-white substance adherent to the stain that serves as a stain lubricant.
   • It is helpful for protecting the baby against infections and should not be taken off
7. Mongolian Spots
   • These are collections of pigment cells.
   • 90% of African infants, 81% of Asian, & 9.6% of Caucasian infants have this
   • It is slate-gray to blue – black lesions
   • It is usually over the lumbosacral area & buttocks
   • It is an accumulation of melanocytes within the dermis
   • They disappear by school age without treatment,

FEATURES IN APPEARANCE OF NORMAL TERM AND PRETERM NEONATES

Features	Term	Preterm
Skin	Pink Well nourished Less fine-hair	Dark Transparent More fine-hair
Ear	Good ear figuration Well developed cartilage	Soft ear stick to the skull Poor figuration
Sole markings	Obvious Over all of sole	Shallow Less markings

 

ENLARGEMENT OF THE BREASTS

• Enlargement of the breasts and production of milk may occur at the age of 3 to 5days in some newborns
• It stops @ the postnatal age of 2-3 weeks.
• It is also caused by transmission & withdrawal of maternal hormones
• This requires no management.

 

Essential NEWBORN INTERVENTIONS IN CARE

1.  Clean childbirth and cord care
   • Prevents newborn infection
2. Thermal protection
   • Prevents and manage newborn hypo/hyperthermia
3. Early and exclusive breastfeeding
   • Started within an hour after child birth
4. Initiation of breastfeeding & resuscitation.
   • Early asphyxia identification a management,

 

NEWBORN REFLEXES

Note 

• Reflex of Spinal automatism = grasping reflex, moro reflex, and stattle reflex
• Reflex of oral automatism = Lip trunk reflex, babkin’s reflex
• only a moron scares a baby
• kernig reflex a child with meningitis

1. SUCKING REFLEX
   1. When a newborn lips are touched, the baby makes a sucking motion
   2. This reflex helps a newborn find food (when lips touch breast / bottle)
   3. It begins to diminish @ about 6 months.
   4. * Place a pacifier (never use your finger) in neonates mouth, neonate sucks on the pacifier
2. ROOTING REFLEX
   1. If the cheek is brushed or stroked near the corner of the mouth, a newborn infant will turn the head in that direction
   2. This reflex also helps newborn find food (turn towards breast)
   3. It disappear @ about the 6th week of life. (3-4 months)
   4. * Touch a pacifier to neonates cheek or corner of mouth, neonate turns head towards stimulus, opens mouth a searches for the stimulus.
3. BLINK REFLEX
   1. Bright light shining in eyes or clap hands near eyes and neonate closes eyelids quickly to use
   2. A sudden movement toward the eye can also elicit the blink reflex.
4. SWALLOWING REFLEX
   1. Food that reaches the posterior portion of the tongue is automatically swallowed.
   2. Gag, cough and sneeze reflexes are present to maintain airway in the event that normal swallowing does not keep the pharynx free from obstructing mucous.
5. MORO REFLEX (reflex of spinal automatism)
   1. Baby is held horizontally, then swiftly lowered a few inches or head may be lowered a few inches, or a loud noise is made
   2. Baby’s arms fling out and then come together as hands open then clutch.
   3. Absence or weakness of this reflex may suggest a severely disturbed CNS
6. STARTLE REFLEX.
   1. Sudden loud noise causes abduction of the arms with flexion of elbow, band remains clenched.
   2. Disappears by age 4
7. PALMAR GRASP REFLEX
   1. Newborn grasps an object placed in their palm by closing fingers on it.
   2. Mature newborns grasp so strongly that they can be raised from a supine position & suspended momentarily from an examiners hand fingers
   3. Reflex disappears around month 3.
   4. * Place a finger in neonates palm, neonate grasps finger
8. PLANTAR GRASP
   1. Pressing thumbs against the balls of baby’s feet will make his toes flex.
   2. Absence of this re flex may indicate damage to spinal cord.
9. STEPPING REFLEX
   1. Hold neonate in an upright position and touch one foot lightly to a flat surface (such as the bed)
   2. Neonate makes Walking motions with both feet
10. BABKIN REFLEX
    1. When both of baby’s palms are pressed;
       • Eyes will close
       • Mouth will open
       • Heaol will turn to one side.
    2. Absence of this reflex or its reappearance after vanishing around 3-4 months may signify malfunctioning CNS.
11. BABINSKI REFLEX
    1. Baby’s foot is stroked from heel toward the toes
    2. The big toe should lift up, while others fan out
    3. Absence of this reflex suggests immaturity of CNS, defective spinal cord, or other problems.
12. TONIC NECK REFLEX (FEENCING POSTURE)
    1. When the newborn lies on his back, his head usually turns to one side or the others.
    2. The arm and legs on the side towards which head turns extend, and opposite arm and leg contract
    3. Also called boxer or fencing reflex
    4. Disappears between 2nd  and 3rd month
13. EXTRUSION REFLEX
    1. Newborn extrudes any substance that is placed on the anterior portion of the tongue.
    2. This protective reflex prevents the swallowing reflex of inedible substances.
    3. It disappears @ about 4 months of age.
14. OTHER REFLEXES
    1. Landau reflex (righting reflex), appears @ 4 months
    2. Glabellar reflex-unconditioned reflex of newborn, persists throughout life
    3. Asymmetric neck reflex Atonic neck reflex.

GROWTH AND DEVELOPMENT OF THE CHILD 

• Growth and development referred to as a unit that  expresses the sum of the numerous changes that take place during an individuals lifetime.
• It is a dynamic process
• It encompasses several interrelated dimensions.

GROWTH 

• Implies a change in quantity
• Results when cells divide & synthesize new proteins.
• Increase in number of cells & their size is reflected in increased size and weight of the whole or any of its parts.

 

MATURATION 

• Literally means to ripen
• Described as aging or as an increase in competence & adaptability.
• Usually used to describe a qualitative change (change in complexity of a structure that makes it possible to function @ a higher level)
• Sometimes maturation designates the unfolding of traits inherent in the organism.

 

DIFFERENTIATION 

• A biological description of the processes by which early cells structures are systematically modified & altered to achieve specific a characteristic physical & chemical properties.
• Also used to describe one of the trends in development (it is’t too specific)

 

DEVELOPMENT

• This is a gradual growth & expansion
• Involves a change in this case from a lower to a more advanced stage of complexity. His the emerging & expanding of capacities of the ind. to provide

• It is the emerging & expanding of capacities of the individual to provide progressively greater facility in function
• It is achieved through growth maturation and learning.

 

STAGES OF DEVELOPMENT 

• Child growth & behavior is categorized into approximate age stages or in terms of features of an age group
• These categories can’t be applied to all children with any degree of precision due to individual differences
• These categories however affords convenient means to describe the characteristics associated with the majority of children @ periods when distinctive developmental changes appears and specific developmental tasks must be accomplished.
• It is also significant for doctor to know that there are characteristic health problems peculiar to each major phase of development.

 

1. PRE-NATAL PERIOD
   1. Embryonic period(conception to 8weeks of gestation)
      1. Embryopathies
         1. Anencephalia
         2. Hydeocephaly
         3. Pylorostenosis
         4. Congenital malformation of lungs, kidney
         5. Congenital heart defect
   2. Fetal period (8 weeks of intrauterine life (till birth))
      1. Fethopathies
         1. Microsomnia (decrease of parts of body)
         2. Hypoplasia (underdevelopment organs/system)
         3. Macrosomia (increase the size of some body parts)
         4. Intrauterine infection (hepatitis, rubella, mycoplasmosis, toxoplasmosis, herpetic infection)
2. Infancy Period
   1. Neonatal Period (Birth to 28 days)
      1. Common diseases of neonates
         1. Embryopathy
         2. Fetopathy
         3. Intrauterine infection
         4. Birth injuries (skull fracture, cephalhematoma, caput succedaneum, fractures of clavicle, humerus, facial paralysis, brachial palsy).
   2. Infancy period (1 month to 12 months)
      1. Common disease of infants
         1. Rickets
         2. Anemia
         3. Acute pneumonia
         4. Infantile eczema
         5. Hypotrophy, paratrophy, acute diarrhoea, acute respiratory viral infection
   3. The infancy period is one of rapid motor, cognitive & social development
   4. Through mutuality with the caregiver (mother), the infant establishes a basic trust in the world & the foundation for future interpersonal relationships
   5. The critical 1st month of life, although part of the infancy periodist offen differentiated from the remainder because of the major physical adjustments of the mother.

 

FINE MOTOR INFANT 

• Newborn – Has little control (grasps & drops objects involuntarily without notice) 
• 6-months – Palmar grasp (uses entire hand to pick up an object) 
• 9 months – pincer grasp (can grasp small objects using thumb & forefinger

 

HEARING

• BAER ( brain-stem auditory evoked response) hearing test is done at birth 
• Ability to hear correlates with ability to enunciate words properly 
• Always ask about history of otitis media – ear infection, placement of – PET tubes in ear
• Early referral to MD to assess for possible fluid in ears (effusion ) 
• Repeat hearing screening test.
• Get speech therapist 

 

RED FLAGS IN INFANT DEVELOPMENT

1. Unable to sit alone by 9 months 
2. Unable to transfer objects from hand to hand by 1yr.
3. Frequent falling and difficulty with stairs.
4. Persistent drooling or very unclear speech.
5. Inability to build a tower of more than 4 blocks.
6. Difficulty manipulating small objects.
7. Inability to copy a circle by 3 years old.
8. Inability to communicate in short phrases.

 

Modern CLASSIFICATION OF PERIODS OF DEVELOPMENT

1. Preembryonic 
2. Intrauterine period (stage of embryonic a placenta development)
3. Newborn period
4. Infant Period
5. Period of deciduous (MILK) teeth teenager 
6. Pre-preschool period 
7. Preschool period, 
8. School period
9. Adolescent period

 

Note:

For monitoring adequacy & inadequacy of growth:

1. Sigma table
2. percentile table
3. Empirical formula