General Pediatric Considerations, Development, Nutrition, and Sleep
Thermoregulation
Cathy Haut
Background/Definition/Pathophysiology
Thermoregulation is important in pediatric acute care evaluation and management.
Hypothermia and hyperthermia can be symptoms of illness or side effects/complications of therapy effects or complications of therapy.
Maintenance of a normal temperature assists in sustaining normal metabolic rate and hydration, thus decreasing additional demands on the ill child, especially a child with an acute or critical illness.
Heat Loss Concepts
Evaporation of fluids through skin and respiratory tract into the air or environment.
Convection is the transfer of heat from one place to another by the movement of air or fluids.
Conduction is the transfer of heat from one surface to another; body conducts heat to whatever surface it is in contact with.
Radiation is heat generated from the body emitted to the surrounding air or environment.
Physioanatomic thermal considerations in children include the following:
Larger body surface area to body mass ratio; increased risk for evaporative loss.
Higher metabolic rates.
Lower subcutaneous fat stores.
Additional risks for temperature instability for premature infants:
Immature central nervous system: insufficient metabolic response to thermal stress.
Low birth weight.
Very little subcutaneous fat, immature skin, and decreased brown fat (presence of brown fat facilitates heat production).
Clinical Presentation
Acute and critically ill infants and children can present with hyperthermia or hypothermia as a symptom or response to illness/disease.
Temperature alteration can result in tachycardia, tachypnea, irritability, dehydration, acidosis and increased metabolic rate.
Management
Recognition of febrile or hypothermic states is essential while determining the etiology and correcting to normothermia.
Maintenance of neutral thermal zones with prevention of heat loss is important for all children, but imperative for preterm infants.
PEARLS
Heart rate and respiratory rate/status can be indicators of fever or hypothermia.
Fever is most commonly a symptom of illness and is vital to immune response.
Antipyretics should be used primarily for comfort rather than for fever reduction.
In some conditions (e.g., traumatic brain injury, cerebral anoxia, post-cardiac arrest), hypothermia may be used as a neuroprotective strategy.
Central Nervous System
Cathy Haut
Background/Definition
The central nervous system (CNS) develops from the embryonic stage until adolescence.
Vulnerable periods during the development of the nervous system include illness; environmental and chemical insults predispose infants and young children to potential sensory,
motor, and cognitive dysfunction with possible poor neurodevelopmental outcomes.
3% to 8% of infants born in the United States will be affected by a neurodevelopmental disorder such as attention-deficit/hyperactivity disorder (ADHD), autism, developmental delay, or cognitive disability which may be associated with insults to the CNS at a young age.
The CNS of preterm and very young infants is especially vulnerable to insult.
Anatomy of the Nervous System
Principal components include CNS and peripheral nervous system.
CNS comprises the brain and spinal cord:
Brain stem:
Medulla oblongata: ascending and descending motor function.
Pons Varolii: connects midbrain with medulla oblongata and controls breathing.
Midbrain:
Contains the dorsal rectum, which is the reflex center controlling movement of the eyeballs and head.
Diencephalon:
Thalamus: interpretation of stimuli, especially pain and temperature.
Hypothalamus: autonomic functions related to homeostasis.
Cerebrum:
Cerebral cortex: frontal, parietal, temporal, and occipital lobes.
Controls voluntary actions, speech, senses, thought, and memory.
Cerebellum:
Controls equilibrium and coordination, muscle movement, and tone.
Cranial nerves:
Twelve cranial nerves.
Cranial nerve function is further explained in the Neurologic section.
Ventricular system includes four ventricles.
Circulates cerebrospinal fluid through the brain, spinal cord, and ventricles.
Peripheral nervous system:
Connects the brain and spinal cord with sensory receptors, muscles, and glands in the limbs and organs.
Somatic nervous system:
Coordinates body movements and receives external stimuli.
Autonomic nervous system:
Controls glands, cardiac muscle, and smooth muscle.
Fluid, Electrolytes, and Nutrition
Cathy Haut
Background and General Concepts
The balance of maintaining fluid, electrolyte, and nutritional status in an acute or critically ill child is challenging and requires precision in assessment and determination of management.
Fluid and electrolyte status is affected by disease state, exhibited by dehydration, overhydration, acidosis, alkalosis, or electrolyte derangements.
Fluid and Nutritional Status
Fluids: 29% extracellular, 19% interstitial, 6% plasma, protein, and lipids, and 45% intracellular.
Infants are more vulnerable to dehydration.
Moderate-to-severe dehydration leads to hypovolemic shock.
Fluids are calculated based on daily needs for healthy children, physiologic state, and insensible losses.
Despite availability of several methods of calculating nutritional deficits, fluid deficits, and fluid requirements, metabolic response to stress, injury, surgery, or inflammation cannot always be accurately predicted; continuous evaluation is required.
Accurate evaluation of energy requirements (indirect calorimetry) and provision of fluids, electrolytes, and optimal nutritional support therapy utilizing the appropriate route are important goals of pediatric acute and critical care.
Malnutrition in hospitalized children is associated with increased physiologic instability and increased resource utilization, with potential poor outcome from critical illness, but recent research indicates that nutritional deficits in early illness do not always result in poor outcomes.
Both overfeeding and underfeeding hospitalized children can affect outcomes.
Altered metabolism occurs in hospitalized children based on severity of injury or illness.
Burns or major trauma affects fluid and electrolyte status and metabolic rates.
Catecholamines (endogenous and exogenous) result in reduction of insulin secretion and peripheral insulin action and stimulate production of glucagon and adrenocorticotropic hormone, resulting in hyperglycemia, lipid intolerance, and protein catabolism in acutely and critically ill children.
Hepatic protein synthesis changes during periods of inflammation, resulting in increased production of C-reactive protein (CRP) and reduced production of albumin and prealbumin.
Pathophysiology
Acute injury markedly alters fluid and energy needs and produces a catabolic response that is proportional to the magnitude, nature, and duration of the injury.
Increased serum counterregulatory hormone concentrations induce insulin and growth hormone resistance, resulting in the catabolism of endogenous stores of protein, carbohydrate, and fat to provide essential substrate intermediates and energy necessary to support ongoing metabolic stress response.
See Section 16 for additional information on fluids and electrolytes.
PEARLS
Fluid, electrolyte, and nutritional concerns are necessary components of every child’s evaluation.
Reevaluation of fluid, electrolyte, and nutritional needs are required with changes in patient’s clinical status.
Pediatric Pharmacokinetics and Pharmacodynamics
Alyssa Cavanaugh
Rosanna Tran
Leah Molloy
Drug Absorption
Oral absorption is generally slower in neonates and young infants.
Gastrointestinal tract pH changes over time.
Compared to older children and adults, neonates have less acidic gastrointestinal tracts with a relatively high pH (>4).
Increased oral bioavailability of acid-labile compounds, such as penicillin G, so may require smaller doses.
Decreased oral bioavailability of weak acids, such as phenobarbital, so may require larger doses.
Enhanced percutaneous absorption during infancy owing to thinner skin, much higher ratio of total body surface area to body mass.
Intramuscular drug absorption.
Despite reduced skeletal muscle blood flow potentially decreasing drug absorption, the greater vascularity of infant skeletal muscle permits equal, if not greater, intramuscular drug absorption.
Drug Distribution
Neonates and infants have high proportions of total body water.
Greater hydration of adipose tissue can yield lower serum concentrations of hydrophilic drugs because they are more liable to distribute into the adipose tissue.
Circulating plasma proteins.
Neonatal albumin has less affinity for weak acids than that of adults and may result in greater free fractions (i.e., not bound to protein) of medications.
Ceftriaxone and sulfamethoxazole compete with bilirubin for binding to albumin in neonatal patients.
Increased concentrations of free bilirubin increase the risk for kernicterus; thus, these agents are avoided in neonates.
Metabolism:
Phase I enzymes: cytochrome P450 (CYP) enzymes.
Different CYP isozymes mature at different rates.
Age-dependent variation in CYP-mediated drug metabolism.
CYP3A7 peaks shortly after birth and declines to undetectable levels in adults.
Hours after birth, CYP2E1 increases to a detectable level and CYP2D6 soon after follows suit.
CYP3A4, 2C9, and 2C19 appear in the first week of life.
CYP1A2 appears 1 to 3 months after birth.
Caffeine and theophylline are substrates for CYP1A2.
May need higher doses as CYP1A2 matures.
Phase II enzymes: glucuronosyltransferase (UGT).
Delayed maturation of UGT1A1, the enzyme responsible for conjugating bilirubin, contributes to higher levels of circulating unconjugated, insoluble bilirubin.
UGT2B7, responsible for metabolizing morphine in preparation for elimination, is present in infants as young as 24 weeks and increases markedly between 27 and
40 weeks of gestation.
Clearance of morphine is correlated with postgestational age, requiring increasing doses to maintain appropriate analgesia as the patient ages, particularly among premature infants.
Elimination:
The processes of glomerular filtration, tubular secretion, and tubular reabsorption determine the efficiency of renal excretion of drugs and their metabolites.
These processes may not develop fully for several weeks to 1 year after birth.
Age-related renal function:
The glomerular filtration rate may be as low as 0.6 to 0.8 mL/minute per 1.73 m2 (0.006-0.008 mL/second/m2) in preterm neonates and approximately 2 to 4 mL/minute per 1.73 m2 (0.02-0.04 mL/second/m2) in term neonates.
Creatinine clearance (CrCl) in children may be estimated using the revised Schwartz equation with an age-dependent variable for infants.
Box 1.1 Revised Schwartz Equation
CrCl = [k × height (cm)]/serum creatinine
Age-specific k values are available in some references; typically k = 0.413.
Additional considerations for pediatric drug dosing:
Doses are typically based on weight and body surface area.
Higher weight-based doses are often needed in children than in adults to achieve comparable exposures.
Voriconazole doses >7 mg/kg are needed for children to achieve similar exposure as adults receiving only 4 mg/kg.
Doses given to children should not exceed maximum adult doses—important for obese pediatric population.
As children clear medications more quickly, shorter dosing intervals are often needed as compared to adults.
Therapeutic drug monitoring:
Some medications have variable dose-exposure relationships and narrow therapeutic indices, necessitating monitoring of serum drug concentrations to guide dosing.
Most common examples are vancomycin, aminoglycosides, and antiepileptics.
Target serum concentrations are patient- and indication-specific; however, typical targets are listed below:
Vancomycin: trough 10 to 20 mg/kg.
Gentamicin, tobramycin: peak 6 to 12 mg/L, trough <1 mg/L.
Phenytoin: steady-state concentration 10 to 20 mg/L.
Normal Childhood Development
Cris A. Bowman-Harvey
Prenatal/Newborn
Health history:
Family health history: chronic and genetic diseases of both maternal and paternal relatives.
Pregnancy history: planned or unplanned, number of live births, abortion or miscarriage, health of other children.
Obstetrics history:
Parent ages, maternal health to include hypertension and epilepsy, prenatal care and course, medications (both prescribed and illicit use) during pregnancy, maternal alcohol and cigarette use, and maternal exposures during pregnancy which can include radiation and other environmental substances (including tobacco exposure).
Maternal infection history: group B streptococcus status
(if known); chlamydia; gonorrhea; hepatitis B; syphilis; HIV.
Maternal infection or exposure history and resulting problems with infant: TORCH.
Toxoplasmosis: cognitive impairment, learning disabilities, and blindness.
Rubella: deafness, blindness, cardiac anomalies, and limb deformities.
Cytomegalovirus: Asymptomatic; symptoms present at birth or may appear more than 2 years after birth and include hearing loss, cognitive impairment, learning disabilities.
Herpes Simplex Virus (HSV): CNS involvement, skin, eye, and mouth involvement, and liver damage.
Maternal Rh and blood-type incompatibilities: RhoGAM administration.
Maternal diabetes: large for gestational age (LGA) infants, hypoglycemia, polycythemia.
Intrauterine issues and associated conditions:
Polyhydramnios can predispose the fetus to umbilical cord prolapse, duodenal atresia, esophageal atresia, intestinal atresia, neuromuscular disorder (e.g., anencephaly), dysplastic kidneys, placental abruption, premature birth, still birth, congenital defect.
Oligohydramnios can predispose the fetus to intrauterine growth retardation (IUGR), umbilical cord compression, musculoskeletal abnormalities, and pulmonary hypoplasia.
Prenatal testing:
Ultrasound: size of infant, presence of single or multiple gestations, gross defects.
α-Fetoprotein measurement: increases as pregnancy progresses to peak during second trimester; good indicator of pregnancy progress; high levels may indicate neural tube defects, multiple gestations, omphalocele, gastroschisis, or nonspecific chromosomal abnormalities.
Amniocentesis: increased risk of abortion; offers identification of infant’s karyotype, enzyme abnormalities, and DNA sampling.
Chorionic villus sampling: performed at 10 weeks’ gestation or later; identification of infant’s karyotype, enzyme abnormalities, and DNA sampling; increased risk of amputation of fingers and toes; slight risk of abortion.
Labor and delivery history:
Type of delivery: cesarean section or vaginal birth; position or presentation of newborn (breech); forceps or vacuum delivery; duration of labor; hours of membrane rupture prior to deliver; analgesia or anesthesia.
Fever: American Academy of Pediatrics (AAP) Guidelines for prevention of perinatal group B streptococcal (GBS) disease (AAP, 2011), chorioamnionitis.
Fetal stress or distress prior to delivery: meconium staining, fetal hypoxia.
Environmental/Social history:
Type, size, and condition of home, heating, and hot water.
Number and relationship of people living in the household; demographics including educational level of parents, medical insurance, and income.
Health and safety hazards in household, guns, tools, and tobacco exposure.
Primary caregiver and care giving arrangements.
Transition to extra-uterine life:
Respiratory system: reabsorption of fetal lung fluid.
Sufficient lung surfactant → increased functional residual capacity → decreased inspiratory pressure → alveolar filling → decreased pulmonary vascular resistance → increased blood flow to the lungs.
Circulatory system: decreased pulmonary vascular resistance → decreased pressure on the right side of the heart (now lower than left side) → foramen ovale closure. Increased blood oxygen level and decreased pulmonary vascular resistance → ductus arteriosus closure.
APGAR score:
Evaluates heart rate, respiratory effort, muscle tone, reflexes, and color, each parameter on a 3-point scale from 0 to 2, with the highest possible total score of 10.
Performed at 1 and 5 minutes of life; sometimes a 10-minute evaluation is warranted.
Gestational age determination:
Maturational assessment of gestational age is based on physical examination to confirm dates and prenatal ultrasound measurement.
LGA infant: >90th percentile can result in hypoglycemia, fracture of clavicles, brachial plexus injury, skull injuries, facial palsy, polycythemia.
Prematurity:
Classification:
Preterm infant: <37 weeks gestation.
Late preterm infant: 34 through 36
= weeks gestation.
Very preterm infant: <32 weeks gestation.
Low birth weight: <2,500 g.
Very low birth weight: <1,500 g.
Extremely low birth weight: <1,000 g.
Health risks of preterm and low-birth-weight infants:
Respiratory distress, apnea of prematurity.
Increased susceptibility to infections.
Thermoregulation issues.
Patent ductus arteriosus (PDA).
Necrotizing enterocolitis (NEC), gastroesophageal reflux (GER).
Retinopathy of prematurity (ROP).
Intraventricular hemorrhage (IVH).
Anemia.
Hernia/hydrocele/undescended testes.
Decreased efficiency conjugating bilirubin, resulting in hyperbilirubinemia.
Decreased ability to concentrate urine, resulting in risk of dehydration.
Hypocalcemia as a result of decreased levels of parathyroid hormone.
Hypoglycemia as a result of decreased glycogen stores.
Postmaturity: pregnancy >42 weeks of gestation.
Health risks associated with postmaturity:
Susceptibility to perinatal asphyxia resulting from placental degeneration.
Hypoglycemia due to rapid use of glycogen stores.
Dry, peeling skin.
Decreased amniotic fluid; potential distress during labor.
Newborn
Pertinent physical examination findings:
May lose up to 10% of birth weight in first days of life (beyond 10% requires close monitoring; possible hospital admission).
Nutritional needs for growth approximately 100 to 110 kcal/kg/day.
Typical weight gain 0.5 to 1 oz/day.
Reflexes present at birth: sucking, rooting, asymmetric tonic neck, Moro reflex, grasp.
Newborn screening test (blood); also known as metabolic screening.
Each state has different screening parameters.
Performed before infant is discharged from the hospital, but preferably after infant has been fed for 24 to 36 hours and again at 2 to 3 weeks of life.
Commonly tested conditions included in the newborn screening test.
Phenylketonuria (PKU): autosomal recessive disorder; inability to break down the amino acid phenylalanine. See Section 9 for more information.
Galactosemia (GAL): rare autosomal disorder; deficiency in the enzyme needed to metabolize galactose in milk. See Section 9 for more information.
Hypothyroidism: See Section 7 for more information.
Hemoglobinopathies: hereditary disorder; sickle cell anemia (several variations) and thalassemia. See Section 10 for more information.
Congenital adrenal hyperplasia: autosomal recessive disorder; inborn deficiency of various enzymes necessary for the biosynthesis of cortisol. See Section 7 for more information.
Maple syrup urine disease: inherited disorder; inability to metabolize valine, leucine, and isoleucine (amino acids). See Section 9 for more information.
Homocystinuria: deficiency of the enzyme cystathionine synthase needed for cystathionine metabolism; results in mental retardation, seizures, behavior disorders, early-onset thromboses, dislocated lenses, and tall, lanky body type. Treatment includes a methionine-restricted diet; cystine supplement and B6 supplement if responsive.
Biotinidase deficiency: inherited metabolic disorder of biotin reuse or recycling. See Section 9 for more information.
Toxoplasmosis: infection of the fetus with the protozoan parasite Toxoplasma gondii, typically acquired by active infection of the mother during pregnancy. Signs of congenital infection may be present at birth or develop over the first few months of life. Symptoms include CNS abnormalities, enlargement of the liver and spleen, blindness, and mental retardation.
Cystic fibrosis (CF): Autosomal recessive disorder that results in an altered transport of chloride ions. See Section 4 for more information.
Dysmorphology in neonates:
Most infants will have some minor malformations or variations of normal; however, primary dysmorphologic concept is that the greater the number of minor malformations, the greater the likelihood that there will be an underlying major malformation—an infant with three or more minor anomalies has an approximately 20% chance of having an underlying associated major malformation.
The rule of threes: One minor abnormality can indicate a chance of genetic abnormality. If two minor abnormalities, must look for a third. If three minor abnormalities, there is a 90% chance the child has a syndrome.
Minor abnormalities are unusual dysmorphic features commonly located on the face, ears, hair, hands, and feet with no serious medical problems.
Newborn hearing screening:
Universal newborn hearing screening is conducted within 1 month of age.
Failed screening, followed by comprehensive audiologic evaluation no later than 3 months of age. Full guidelines available from AAP: www.aap.org.
Newborn safety:
Infant
First 3 months of age (first 28 days of life is considered neonatal period).
Growth:
0.5 to 1 oz per day with 8 to 10 feedings in 24 hours.
Weight returns to birth weight by approximately 14 days of life.
Height/Length growth is approximately 1 inch per month.
Occipitofrontal head circumference growth approximately 2 cm per month.
Sleep:
Approximately 15 to 16 hours per 24 hours.
Hearing:
Determined through universal hearing screen guidelines.
Gross motor:
Moves head side to side, lifts head when prone.
Fine motor:
Hands closed but will begin to open from fists, palmar grasp.
Language:
Alert to bells or loud sounds.
Strong cry; small throaty sounds when feeding.
Socialization/Cognition:
Regards face.
2 to 6 months of age.
Growth:
Weight gain approximately 0.5 to 1 oz per day or 5 to 7 oz per week.
Birth weight doubles by 4 to 6 months of age.
Height growth approximately 1 inch per month.
Occipitofrontal circumference grows approximately 2 cm per month until 3 months of age, then 1 cm per month.
Posterior fontanel closes by 1 to 3 months of age.
Eyes:
Fuzzy vision as newborn; increases to several feet away at 4 to 5 months of age.
TABLE 1.1 Early Infant Vision and Hearing
Age
Vision
Hearing
2 mo
Follows 30-40 degrees.
Focuses on bright light.
Responds to sound.
Startle reflex.
4 mo
Peripheral vision to 180 degrees; able to track light during examination.
Binocular vision.
Doll’s eye reflex gone.
Turns head toward sound.
6 mo
Fixates on small objects.
Visual accommodation on near objects; able to reach and grasp objects.
Locates objects to side and up and down.
Nose:
Obligate nose breathers.
Genitalia: males.
Testes present and descended by 6 months of age.
If presence of rugae on scrotum, indication that testes descended at some point.
Musculoskeletal:
Hips: no clicks or clunks (i.e., Ortolani and Barlow maneuvers).
Hip ultrasound: indicated for infants with unequal but-tock skin creases.
Skin:
Mongolian spots: benign congenital birth mark.
Café au lait spots: may be faint in infancy and become more noticeable by 2 years of age; associated with neurofibromatosis type 1, McCune-Albright syndrome, tuberous sclerosis, and Fanconi anemia (Tables 1.1 and 1.2).
9 to 12 months of age.
Growth:
Weight gain 3 to 4 oz per week.
Birth weight triples at 12 months of age.
Height growth is approximately ½ inch per month.
At 12 months of age, height is approximately 1.5 times the birth height.
Occipitofrontal circumference growth approximately 1 cm per month.
Screening:
Lead level by 1 year of age; hemoglobin and/or hematocrit (Tables 1.3 and 1.4).
Pertinent physical examination findings:
Head: anterior fontanel 4 to 5 cm after birth; fontanel closes between 12 and 18 months of age.
Eyes: Nasolacrimal duct should be open by 12 months of age.
Neurologic: Primitive reflexes disappear by 1 year of age (persistent reflexes may indicate neurologic abnormalities): Moro relfex, rooting, sucking, stepping, palmar grasp, Babinski, asymmetric tonic neck.
Anticipatory guidance:
Feeding:
Exclusive breast-feeding is the preferred method of nutrition for the first 6 months of life.
Transition to cup by 12 months of age.
TABLE 1.2 Early Infant Motor and Language Development
Age
Gross Motor
Fine Motor
Language
Social/Cognitive
2 mo
Lifts shoulders when prone.
Lifts head when against shoulder.
Some head lag, but head becoming stronger.
Brings hand to mouth.
Cooing.
Responds to human faces.
Begins to smile to stimuli.
Social smile.
4 mo
No head lag when pulled to a sit.
Balances head well when upright.
Rolls from front to back and back to side.
Bears weight when held up.
Reaches for object.
Brings object to mouth.
Laughs and squeals.
Consonant sounds — N, K, G, P, B
Shows excitement with whole body.
Anticipates feeding when sees bottle.
Enjoys social interaction.
Increased interest in caregiver.
Begins to play with toys.
Memory span approximately 5 min.
Turns head to locate sound.
6 mo
Sits alone or forward on hands.
Lifts chest and upper abdomen off table.
Bears weight on hands.
Sits on chair with straight back.
Rolls from back to abdomen.
Transfers object hand to hand.
Drops one block when handed another.
Eye-hand coordination is improving.
Babbles.
Imitates sounds.
Begins to make “ma,” “da,” “ba” sounds.
Holds bottle.
Plays “peekaboo”.
Smiles at self in mirror.
Briefly searches for lost object.
Adjusts posture to see objects.
Begins to respond to name.
Begins object permanence.
Recognizes parent in different setting or clothing.
TABLE 1.3 Late Infancy Vision and Hearing
Age
Vision
Hearing
9 mo
Eye-hand coordination improving.
Can rescue a dropped toy.
Prefers yellow and red.
Eyes are nearing final color.
Responds to name.
Turns head to locate sound in curving arc.
Responds to softer sounds.
12 mo
Has depth perception.
Can recognize familiar individuals approaching from a distance.
Responds to music.
TABLE 1.4 Late Infancy Motor and Language Development
Age
Gross Motor
Fine Motor
Language
Social/Cognitive
9 mo
Able to get into sitting position.
Pulls to stand.
Creeps on hands and knees.
Crude pincer grasp.
Bangs two blocks together.
Can get toy by pulling on string.
Reaches for objects and lets them fall.
Says “dada” or “mama,” but not specific to person.
Responds to simple commands such as “no”.
Comprehends “no-no” and “bye-bye”.
Stranger anxiety at its worst.
Waves “bye-bye”.
Plays “pat-a-cake”.
Fear of being left alone.
Easily frustrated.
Depth perception begins.
12 mo
Stands alone.
Stoops and stands.
Can walk with one hand held.
Crawls to get places quickly.
Firm hold on cup.
Puts block in cup.
Says “mama” and “dada” specific to person.
Says one or two words.
Waves “bye-bye”.
Jabbers.
Mood changes.
Cuddles.
Imitates others.
Searches for hidden toy.
Places objects in a container.
Knows name.
Sleep:
Back to sleep.
Put infant to bed while still awake to learn sleep regimen.
Pacifier at bedtime demonstrated to reduce sudden infant death syndrome.
Immunizations: begin first few days of life and continue throughout lifetime, but are concentrated in the first
2 years. Follow the Centers for Disease Control and Prevention (CDC) annual recommendations.
Safety/Injury prevention:
Falls: stairs, windows.
Home proofing, firearm hazards. Burns/hot liquids.
Smoke detectors/carbon monoxide detectors.
Infant walkers, unsafe unless no wheels.
Ingestions/poisonings, choking/suffocation.
Appropriate size car seat installed correctly (Table 1.5).
Toddler
1 year to 2½ years of age (Tables 1.6 and 1.7).
Pertinent physical examination findings:
Growth:
Gains 4 to 6 pounds per year.
1 year of age: triples birth weight.
2.5 years of age: quadruples birth weight.
Grows approximately 3 inches per year.
Estimated adult height is 2 times 2-year-old height.
Head:
Circumference increases approximately 1 inch per year.
Anterior fontanel closes at 9 to 18 months of age.
Mouth:
20 teeth by 2½ years of age.
First molars: 10 to 16 months of age.
TABLE 1.5 Infancy Developmental Red Flags
0-1 mo
3 mo
6 mo
9 mo
12 mo
Red Flags
Not at birth weight by 2 wk of age.
Poor suck or swallow.
Sweating or fatigue with feedings.
Asymmetrical movements.
Hyper- or hypotonia.
Hands held fisted only.
Irritable.
No startle reflex to loud/sudden noise.
High-pitched cry.
No red reflex.
Poor weight gain.
Occulofrontal circumference not increasing.
Fussy.
Poor suck/swallow.
No attempt to raise head.
Hyper- or hypotonia.
No hand-to-mouth activity.
Feeding taking longer than 45 min.
Lack of social smile.
Does not turn to voice or rattle.
No sounds (e.g., “coo”).
No tracking.
Has not doubled birth weight.
OFC not increasing.
Does not sit without support.
Head lag.
Scissoring.
Does not hold rattle or grasp object.
No smile.
No eye-to-eye contact.
No babbling.
No response to noise. Does not sit.
Asymmetrical crawl.
No self-feeding.
No high chair sitting.
No solids.
Intense or absent stranger anxiety.
Does not seek comfort from caregiver.
No response to name.
No reciprocal vocalization.
Lack of toy exploration.
Has not tripled birth weight.
Not pulling to stand.
Not crawling or mobile.
Not attempting to feed or hold cup.
Not able to hold toy in each hand or transfer objects.
No vocalization.
Not imitating speech.
Does not point or use gestures.
Not saying 2-3 words.
Poor eye contact.
Cuspids (canines): 16 to 20 months of age.
Second molars: 20 to 30 months of age.
Ears:
Hearing loss suggested by absence of communicative speech at 15 months of age.
Abdomen is normally protruberant.
Genitalia:
Males: testicles palpable in scrotum or inguinal canals; foreskin can be retracted (90% by 2 years of age) in uncircumcised males.
Musculoskeletal:
“In-toeing” due to tibial torsion (tibia slightly internally rotated)—usually resolves by 16 to 18 months of age.
“Out-toeing” is a physiologic variant.
Genu varum (bowleg) is normal.
Pes planus (flatfoot) is normal.
Neurologic:
Reflexes.
Landau (lifts head when suspended in prone position— postural reflex) appears at 3 months of age and disappears by 15 months to 2 years of age.
Neck righting (trunk rotates in same direction as head when in supine position) appears at 6 months of age and disappears at 2 years of age.
Parachute (extends arms, hands, and fingers when suspended in prone and lowered quickly—postural reflex) appears at 6 to 8 months of age and remains.
Babinski: normal up to 2 years of age
Screening:
Height, weight, head circumference: at all visits.
Vision: at all visits by history, risk factors, and examination.
Hearing: at all visits by history, risk factors, hearing loss indicators.
TABLE 1.6 Toddler Vision, Hearing, and Physical Development
Age
Vision
Hearing
Physical
1 y
Visual acuity 20/40 to 20/60.
Can follow rapidly moving objects.
If strabismus is present, visual loss possible.
Knows several words and their meanings.
Can control response to sound.
Birth weight tripled.
Birth length increased by 50%.
Head and chest circumferences equal.
Anterior fontanel almost closed.
6-8 deciduous teeth.
Babinski reflex gone.
Lumbar curve developing.
15-18 mo
Binocular vision develops.
Smooth ocular movements.
Good eye-hand coordination.
Responds to whisper test.
Anterior fontanel closes.
Physiologic control of sphincters develops.
Parachute reflex.
2 y
Accommodation well developed.
Has achieved approximately 50% of adult height.
Birth weight quadrupled by 30 mo of age.
May have neurologic readiness for daytime bowel and bladder control.
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