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Introduction to Pediatrics and Neonatology

Examination of a newborn infant

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

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

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

ROLE IN EVALUATION
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 

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

LENGTH / HEIGHT
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

 

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

POSTERIOR FONTANEL

RESPIRATORY SYSTEM 

Fetal Lung Development
Establishment of breathing after birth
Characteristics of Newborn Respiration

APNEA 

Abnormal findings

Circulatory System

Heart rate
Heart murmur
Blood Pressure (@ birth)

HEMATOLOGICAL System

Blood

* 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
Platelet count

Gastrointestinal Tract(GIT) 

ALIMENTARY SYSTEM

HEPATIC FUNCTION

Physiological Jaundice

URINARY SYSTEM

 

KIDNEYS AND URINATION

IMMUNE SYSTEM 

 

NEUROMUSCULAR SYSTEM 

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
NEUTRAL Environmental Temperature
TEMPERATURE REGULATION 

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

 

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 

  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 

 

MATURATION 

 

DIFFERENTIATION 

 

DEVELOPMENT

 

STAGES 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 

 

HEARING

 

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

 

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