Red Flags in Newborn to Preschool Well Exams

1. Red Flags in Newborn to Preschool Well Exams Whitney Lutz, MSN, RN, CPNP

2. Objectives • PARTICIPANTS will : • Appreciate the components of well physical examinations for infants and young children per recommendations from the American Academy of Pediatrics • Understand the basics of developmental progression from birth to preschool age • Be able to recognize some important red flags during well exams involving physical and developmental/neurological variations • DISCLOSURES--- NONE

4. Newborn Growth Marks • Weight– lose up to 10% of BW in first 10 – 14 days. • Should gain 15 – 30 gms. per day till 3 months of life • 3-6 mon. gain 15 gms. daily • 6-12 mon. gain 10 gms. daily • DOUBLE BW BY 3-4 MON • TRIPLE BW BY 12 MON • Watch growth grids for shifts

5. How many kcal intake? • Breast milk and formula are 20 kcal/oz • Average newborn needs 150 to 180ml (5-6 oz) /kg/day to maintain adequate growth • Preterm infants need 120 – 150 kcal/kg/day for growth– can use 22 – 24 cal/oz formula to enhance growth.

6. So, first • Not gaining enough– 38 wk F., BW - 3.6 KG, uncomplicated preg./del., G1P1 with DC wt of 3.41 ( 6%). Bfing in nursery with difficulty • DOL 4– Wt is 3.17 ( 12%) • What do you know are the norms? • What do you want to ask? • What do you assess? • When would you see them back? • DOL 5 Wt is 3.13 kg. ( 13%) • NOW WHAT?

7. Newborn Linear Growth • Average length of NB is 20 in. and grow 10 in. the 1st yr., 4 in. in 2nd yr and ½ adult height by 24 -30 mon. • 0 to 6 months – One inch (2.5 cm) per month • 7 to 12 months – One-half inch (1.25 cm) per month • 12 to 24 months – Usually >4 inches (10 cm) per year • 24 to 36 months – 3 inches (8 cm) per year • 36 to 48 months – 2.75 inches (7 cm) per year

8. Newborn’s Head Growth • Avg. OFC is 35 cm and is 1-2 cm larger than chest until age 24 mon. • Avg. growth is 1 cm a month first 12 mon. • Fastest growth is in first 6 months with 2 cm in first month and 6 cm in first 2-6 months • 60% brain growth by 2 yrs and 90% by 4-5 yo • Macrocephaly: 2 standard deviations above mean (> 97th %) • Microcephaly: 2 standard deviations below the mean (< 5th %)

10. Consider • Look for symmetry • Position of skull bones • Anterior Fontelle • Posterior Fontelle • Suture lines • Any bossing? • Sun-set eyes? Shifting in Growth % What do you think?

11. Okay, another

13. Differential Dx: • INHERITED– 60% • Communicating hydrocephalus • Non-communicating hydrocephalus • Neural Tube defect • Genetic abnormality/Syndromes- NF1, Noonan • Encephalacele • ACQUIRED- 37-39% • Meningitis • TBI • Space occupying lesion

14. How would you proceed? • Good familial and birth history – any neuro or cutaneous disorders? • Thorough physical exam looking for anatomic/ physiologic abnormalities • Good evaluation of neurodevelopment– are they on target or lagging? • Imaging?--- US vs Xray vs CT vs MRI

16. Gross Motor Development

18. DDH--- The Continuum of Hip Displacement

19. RISK FACTORS ??? • FEMALE • BREECH PRESENTATION @ > 34 WKS • + FAMILY HX OF DDH • TIGHT SWADDLING OF LOWER EXTREMITIES • Suggested associated risks: • First born or Multiple births • LGA • Metatarsus Adductus, Clubfoot • Oligohydramnios ,

20. DDH • Continuum of subluxation to dislocation- Barlow & Ortolani (95-99% specificity) • Assymetrical skin folds unilaterally • Apparent shortening of femur– Galeazzi’s • Limited hip abduction to 45 (good specificity) • + Galeazzi’s/Allis • Lateral rotation of femur while prone • Increased skin fold asymmetry • + Klisic test •  Bilateral occurrence 37% of time. Birth 3-4 mon – 12 mon

23. MANEUVERS FOR DDH

24. Ambulatory changes w DDH • Excessive lordosis • Trendelenburg gait • Positive Trendelenburg • Waddling gait : Ambulatory changes w DDH • external rotation of affected side • Increased adduction contracture of hip with compensatory genu valgus

25. Trendelenburg • Observe from behind • Pelvis tilts down toward UNAFFECTED side when standing on affected leg due to gluteal muscle weakness

26. What to do about this? • Birth to 12 wks of age--- ultrasound • WHY AN ULTRASOUND? • Should have US @ 6 wks age if breech birth or family hx of DDH • Xray at 4-6 months– AP in 20 flexion • Referral to Ortho?--- Positive Ortolani’s • Barlow– can follow closely for several weeks • Older infant/child with positive findings-- refer

27. Treatment • Birth to 6 mon--- Pavlik Harness • 6 mon to 18 mon– closed or open reduction and spica cast • 18 mon to 48 mon– closed or open reduction • osteotomies

28. Screening for Anemia • Routinely done at 12 mon well exam– H & H– WHY? • Factors that effect H & H? • What are the norms? • HGB– 11 to 13.5 gms/dl • HCT- 38 to 32 % • IDA is: serum ferritin < 12 mcg/L AND • HGB < 11 g/dl in children 12 mon to 48 mon.

29. Dietary Causes of IDA • ●Insufficient iron intake • ●Decreased absorption due to poor dietary sources of iron • ●Introduction of unmodified cow's milk (non-formula cow's milk) before 12 months of age • ●Occult blood loss secondary to cow's milk protein-induced colitis

30. How much do you need??? • Infants • •Full-term – 1 mg/kg daily (maximum 15 mg) • •Premature – 2 to 4 mg/kg daily (maximum 15 mg) • ●Children • •1 to 3 years old – 7 mg daily • •4 to 8 years old – 10 mg daily

31. Last Red Flag • 13 mon. old well exam– 75th% weight/50th% ht • Meeting dev. Milestones appropriately • Diet: weaned to WM at 11 mon. – 36 oz / day eating small amounts table foods– squash, carrots, fruits, baby yogurt, cheerios, puffs. • Hgb- 8.7 gm/dl and Hct 26% • DX:? • Possible physical exam findings: exercise fatigue tachycardia, soft murmur, pallor of membranes, irritable, poor feeding habits

32. Dx of Iron Def. Anemia • What to do about this? • Get CBC w diff, RBC indices, • Can consider serum Ferritin and Retic count • Might consider CRP with Ferritin as it can be elevated in presence of inflammation. • What are you looking for? • IDA– HGB < 11 g/dL, MCV down and RDW up

33. Treatment • Ferrous Sulfate at 3-6 mg/kg/day in twice a day dosing • Give between meals • Give with Vitamin C to help with absorption • Can stain teeth so use caution • Recheck HGB in one month and should increase by 1 gm/dL