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
- Infants
- Children
- Adolescents
The age limit usually ranges from birth till 18
DIFFERENCES BETWEEN ADULT AND PEDIATRIC MEDICINE
- Body size differences maturation differences in adults.
- Congenital defects, genetic variance and developmental issues are great in children
- Pediatrics involves treatment of both the child a parents (even whole family)
WORK STYLES
- Independence
- Self control
- Adaptability / flexibility in loca
- Cooperation
TASKS
- Examine patients or order, perform and interpret diagnostic tests to obtain info on medical condition and determine diagnosis.
- Advise patients, parents and community members concerning diet, activity, hygiene and disease prevention
- Explain procedures and discuss test results or prescribed treatments with patients a parents guardians
- Monitor patients condition, progress and reevaluate treatments as necessary.
- Plan and execute medical care programs to aid in the mental and physical growth a development of children & adolescents.
- Direct and coordinate the activities of nurses, students, assistants, Specialists, therapists & other medical staff.
HEALTH INDICES
- General birth rate of the population (%) = (The number of people born alive during 1 year x 1000)/Mid-annual population
- General mortality rate of the population (%) = (The number of people who died during 1 year x 1000)/Mid-annual population
- 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
- 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
- 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
- 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
- Full term infant. – An infant born @ a gestational age between 37 and 42 completed weeks
- Pre-term infant – An infant born prior to 3 weeks of gestation (22 – 37 weeks or weight greater than 500 g)
- Post term infant – An infant born after the 42nd week of gestation
ACCORDING TO RELATIONSHIP BETWEEN GA AND BW
- AGA (Appropriate for Gestational Age) – Infants with birth weight for their gestation age that falls – between the 10th & 90th percentiles.
- SGA (Small for Gestational Age) – Infants with birth weight for their gestational age that falls below the both percentiles.
- 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
- Evaluate the conditions of the baby@ birth
- Deferring the need for resuscitation
- Evaluate effectiveness of resuscitation efforts
- 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
- Healthy newborn 7-10 @ both 1 and 5 minutes
- Moderately depressed newborn 3-6 (Need resuscitation)
- 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
- Mean normal growth = 25-75-90 i
- Mean less than average data= 10-252
- mean greater than average data = 75-90
- Mean low data = 3-10
- Mean high data = 90-97
- Mean extremely low data = Below 3
- 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
- INGESTION OF Colostrum / FORMULA (Gradual transition) – Few greenish stools to gradual yellow 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
- ACROCYANOSIS
- Result of sluggish peripheral circulation
- 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.
- 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.
- 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.
- 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,
- 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
- 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
- Clean childbirth and cord care
- Prevents newborn infection
- Thermal protection
- Prevents and manage newborn hypo/hyperthermia
- Early and exclusive breastfeeding
- Started within an hour after child birth
- 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
- SUCKING REFLEX
- When a newborn lips are touched, the baby makes a sucking motion
- This reflex helps a newborn find food (when lips touch breast / bottle)
- It begins to diminish @ about 6 months.
- * Place a pacifier (never use your finger) in neonates mouth, neonate sucks on the pacifier
- ROOTING REFLEX
- If the cheek is brushed or stroked near the corner of the mouth, a newborn infant will turn the head in that direction
- This reflex also helps newborn find food (turn towards breast)
- It disappear @ about the 6th week of life. (3-4 months)
- * Touch a pacifier to neonates cheek or corner of mouth, neonate turns head towards stimulus, opens mouth a searches for the stimulus.
- BLINK REFLEX
- Bright light shining in eyes or clap hands near eyes and neonate closes eyelids quickly to use
- A sudden movement toward the eye can also elicit the blink reflex.
- SWALLOWING REFLEX
- Food that reaches the posterior portion of the tongue is automatically swallowed.
- 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.
- MORO REFLEX (reflex of spinal automatism)
- Baby is held horizontally, then swiftly lowered a few inches or head may be lowered a few inches, or a loud noise is made
- Baby’s arms fling out and then come together as hands open then clutch.
- Absence or weakness of this reflex may suggest a severely disturbed CNS
- STARTLE REFLEX.
- Sudden loud noise causes abduction of the arms with flexion of elbow, band remains clenched.
- Disappears by age 4
- PALMAR GRASP REFLEX
- Newborn grasps an object placed in their palm by closing fingers on it.
- Mature newborns grasp so strongly that they can be raised from a supine position & suspended momentarily from an examiners hand fingers
- Reflex disappears around month 3.
- * Place a finger in neonates palm, neonate grasps finger
- PLANTAR GRASP
- Pressing thumbs against the balls of baby’s feet will make his toes flex.
- Absence of this re flex may indicate damage to spinal cord.
- STEPPING REFLEX
- Hold neonate in an upright position and touch one foot lightly to a flat surface (such as the bed)
- Neonate makes Walking motions with both feet
- BABKIN REFLEX
- When both of baby’s palms are pressed;
- Eyes will close
- Mouth will open
- Heaol will turn to one side.
- Absence of this reflex or its reappearance after vanishing around 3-4 months may signify malfunctioning CNS.
- When both of baby’s palms are pressed;
- BABINSKI REFLEX
- Baby’s foot is stroked from heel toward the toes
- The big toe should lift up, while others fan out
- Absence of this reflex suggests immaturity of CNS, defective spinal cord, or other problems.
- TONIC NECK REFLEX (FEENCING POSTURE)
- When the newborn lies on his back, his head usually turns to one side or the others.
- The arm and legs on the side towards which head turns extend, and opposite arm and leg contract
- Also called boxer or fencing reflex
- Disappears between 2nd and 3rd month
- EXTRUSION REFLEX
- Newborn extrudes any substance that is placed on the anterior portion of the tongue.
- This protective reflex prevents the swallowing reflex of inedible substances.
- It disappears @ about 4 months of age.
- OTHER REFLEXES
- Landau reflex (righting reflex), appears @ 4 months
- Glabellar reflex-unconditioned reflex of newborn, persists throughout life
- 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.
- PRE-NATAL PERIOD
- Embryonic period(conception to 8weeks of gestation)
- Embryopathies
- Anencephalia
- Hydeocephaly
- Pylorostenosis
- Congenital malformation of lungs, kidney
- Congenital heart defect
- Embryopathies
- Fetal period (8 weeks of intrauterine life (till birth))
- Fethopathies
- Microsomnia (decrease of parts of body)
- Hypoplasia (underdevelopment organs/system)
- Macrosomia (increase the size of some body parts)
- Intrauterine infection (hepatitis, rubella, mycoplasmosis, toxoplasmosis, herpetic infection)
- Fethopathies
- Embryonic period(conception to 8weeks of gestation)
- Infancy Period
- Neonatal Period (Birth to 28 days)
- Common diseases of neonates
- Embryopathy
- Fetopathy
- Intrauterine infection
- Birth injuries (skull fracture, cephalhematoma, caput succedaneum, fractures of clavicle, humerus, facial paralysis, brachial palsy).
- Common diseases of neonates
- Infancy period (1 month to 12 months)
- Common disease of infants
- Rickets
- Anemia
- Acute pneumonia
- Infantile eczema
- Hypotrophy, paratrophy, acute diarrhoea, acute respiratory viral infection
- Common disease of infants
- The infancy period is one of rapid motor, cognitive & social development
- Through mutuality with the caregiver (mother), the infant establishes a basic trust in the world & the foundation for future interpersonal relationships
- 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.
- Neonatal Period (Birth to 28 days)
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
- Unable to sit alone by 9 months
- Unable to transfer objects from hand to hand by 1yr.
- Frequent falling and difficulty with stairs.
- Persistent drooling or very unclear speech.
- Inability to build a tower of more than 4 blocks.
- Difficulty manipulating small objects.
- Inability to copy a circle by 3 years old.
- Inability to communicate in short phrases.
Modern CLASSIFICATION OF PERIODS OF DEVELOPMENT
- Preembryonic
- Intrauterine period (stage of embryonic a placenta development)
- Newborn period
- Infant Period
- Period of deciduous (MILK) teeth teenager
- Pre-preschool period
- Preschool period,
- School period
- Adolescent period
Note:
For monitoring adequacy & inadequacy of growth:
- Sigma table
- percentile table
- Empirical formula