Pediatrics

Pediatrics

NEW BORN

Normal human gestational period is 280 days or 40 weeks calculated from the first day of the mother’s last menstrual cycle

•Stillbirth - fetus born with no signs of life ≥24 weeks of pregnancy •Perinatal mortality rate - stillbirths + deaths within the first week per 1000 live births and stillbirths •Neonatal mortality rate - deaths of live-born infants within the first 4 weeks of age per 1000 live births •Neonate - infant ≤28 days old

•Preterm - gestation <37 weeks of pregnancy Term - 37-41 weeks of pregnancy •Post-term - gestation >42 weeks of pregnancy •Low birthweight (LBW) - <2500 g •Very low birthweight (VLBW) - <1500g •Extremely low birthweight (ELBW) - <1000 g •Small for gestational age - birthweight <10th centile for gestational age •Large for gestational age - birthweight >90th centile for gestational age.

The first 28 days of life are usually considered the newborn period (neonatal period); practically extended in a case of a sick or premature infant Evaluation of the Newborn Infant History: Taking the history in newborn medicine involves three key areas: (1) the medical history of the mother and father, including a relevant genetic history; (2) the history of the mother's previous pregnancies; and (3) the history of the current pregnancy, including antepartum and intrapartum events

New Ballard Score for Assessment of Fetal Maturation of Newly Born Infants

Neuromuscular Maturity Physical Maturity

Ballard scoring system

Physical maturity -1 Skin

Lanugo Plantar creases

0

1

2

3

4

5

Physical maturity (contd…) -1 Breast Eye & Ear Genitals, Male Genitals, female

0

1

2

3

4

Maturity rating Maturity

Score

–10

Rating

Weeks 20

–5

0

5

10

15

20

25

30

35

40

45

50

22

24

26 28

30

32

34

36

38

40

42

44

new Ballard Score = = SUM (points for each parameter) Interpretation: • minimum score: -13 • maximum score: 54

Posture

Square window (wrist)

Arm recoil

Popliteal angle

Scarf sign

Heel to Ear

Recall of the date of the last menstrual period is the best indicator of gestational age Other obstetric observations, such as fundal height and early ultrasound examination, provide supporting information Postnatal examination can also be used

Birth weight and gestational age must be plotted on an appropriate standard to determine if the infant's weight is appropriate for gestational age (AGA), small for gestational age (SGA), intrauterine growth restricted (IUGR), or large for gestational age (LGA)

Birth Weight for Gestational Age (GA)

Birth Weight for Gestational Age (GA)

Causes of Variations in Neonatal Size in Relation to Gestational Age: Infants large for gestational age    Infant of a diabetic mother Infants small for gestational age    Asymmetrical     Placental insufficiency secondary to pregnancy-induced hypertension or other maternal vascular disease     Maternal age > 35 years     Poor weight gain during pregnancy     Multiple gestation   Symmetrical     Maternal drug use        Narcotics        Cocaine        Alcohol     Chromosomal abnormalities

LGA babies are at risk for birth trauma, hypoglycemia, polycythemia, congenital anomalies, cardiomyopathy, hyperbilirubinemia, and hypocalcemia. SGA babies are at risk for fetal distress during labor and delivery, polycythemia, hypoglycemia, and hypocalcemia.

In the delivery room, the examination consists largely of observation plus auscultation of the chest and inspection for congenital anomalies and birth trauma

A useful tool for immediate assessment of the newborn  Helps to identify infants requiring resuscitation  Scores given at 1 and 5 min after birth ; may be given every 5 min afterwards  A score of less than 5 indicates a need for assisted ventilation & possible cardiac support  A score of 5-7 indicates a need for stimulation supplemental Oxygen  Score of 8-10 reflects good oxygenation and ventilation 

The Apgar Score

or sneeze motion ,crying

Start with observation, then auscultation of the chest, and then palpation of the abdomen Examination of the eyes, ears, throat, and hips should be done last, since these maneuvers are most disturbing to the infant. The heart rate should range from 120–160 beats/min, and the respiratory rate from 30–60 breaths/min Systolic blood pressure on day 1 ranges from 50–70 mm Hg and increases steadily during the first week of life

Skin Head Face Eyes Nose Ears Mouth Neck Chest & Lungs Heart Abdomen Genitalia & Anus Skeleton Neurologic Examination

Skeletal examination immediately after delivery serves two purposes: (1)to detect any obvious congenital anomalies, and (2)to detect signs of birth trauma, particularly in LGA infants or those born after a protracted second stage of labor—in whom a fractured clavicle or humerus might be found The umbilical cord should be examined for the number of vessels. Normally, there are two arteries and one vein

Skin Skin color is a useful indicator of cardiac output Normally there is a high blood flow to the skin Any stress that triggers a catecholamine response redirects cardiac output away from the skin to preserve oxygen delivery to more critical organs Cyanosis and pallor are thus two signs reflecting inadequate skin oxygenation and cardiac output.

Mangolian spots:  Flat-blue or gray lesions with well-defined margins that generally disappear in the first few years of life  Most common over the presacral area  Secondary to melanin-containing melanocytes found in the dermal layer

Salmon patch: A flat vascular lesion that disappears with time (except in nuchal area); seen over the eyelids, glabella, nuchal area  Capillary (strawberry) hemangiomas: Macular lesion in first few months; quickly grow in the first year of life  Nevus sebaceus: yellow-orange hairless plaques  Café-au-lait spots: tan or light brown flat lesions 

Erythema toxicum: Small papules or pustules on an erythematous base Appear after the first day of life ;may last several weeks; full of eosinophils if scraped  Milia: small inclusion cysts; pearly white  Cutis marmorata: vasomotor response to cold stress  Neonatal acne: can occur due to circulating androgenic hormones 

 Cephalohematoma:

A subperiosteal bleed; does not

cross suture lines  Caput succedaneum: A swelling of the scalp; crosses the suture lines  Subcutaneous fat necrosis: Rubbery, firm nodules palpated on the cheeks or buttocks, back, extremities  Facial palsy  Clavicular fracture  Subconjunctival hemorrhage

 Brachial

injury: Occurs in large infants, secondary to traction on the head during delivery Erb-Duchenne paralysis : injuries of upper brachial plexus or its nerve roots (C5-C6); arm adducted , pronated and internally rotated Klumpke paralysis: injuries of lower brachial plexus or its nerve roots (C7,8;T1); produces paralysis of the hand

Infant with Erb’s palsy

•Muscles of shoulder and upper arm chiefly affected; •elbow extended and wrist flexed; •grasp normal

Young girl with Klumpke’s palsy

•Muscles of forearm and hand chiefly affected; •Grasp weak and affected limb small; •Horner’s syndrome present due to interruption of fibres to cervical sympathetic trunk

Eyes: Colobama: a defect in the lid, ranging from a small notch to a large defect Aniridia: absence of the iris  Ears: pre-aruicular skin tags, pre-auricular pits and malformed ears  Neck: Brachial cleft cysts Congenital torticollis 

Chest:  Breast hypertrophy  Supernumerary nipples  Poland syndrome: amastia, pectoralis muscle aplasia, rib deformities; webbed fingers, radial nerve aplasia  Pectus excavatum (funnel)  Pectus carinatum (pigeon)

Abdomen:  Masses: Hyedronephrosis, Multicystic/polycystic kidney disease  Umbilical hernias  Omphalocele: Herniation of peritoneum and abdominal contents into the base of umbilical cord  Gastroschisis: Herniation without sac, through an abdominal wall defect to the side of the umbilicus

Genitourinary:  Epispadias: urethral opening located on the dorsum of the shaft of the penis  Hypospadias: urethral opening located on the ventral side of the shaft of the penis  Undescended testes: usually in the inguinal canal  Hydrocele: collection of fluid in the scrotum,specially the tunica vaginalis  Hernias; usually inguinal, (usually indirect)