Infant Care

Well-Child Checks

Well-child checks are visits scheduled at crucial ages in a child’s development. These checks are necessary to assess overall health, to provide preventive services, for early detection of disease and abnormalities, and for prompt management of health concerns.

Schedule in the United States

• 3–5 days after birth
• 1 month
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months
• Yearly

Components of the well-child check

• History and physical exam:
  • General: assess alertness, tone, vigor
  • Ocular: assess red reflex Red Reflex Cataracts in Children, symmetry, and motility Motility The motor activity of the gastrointestinal tract. Gastrointestinal Motility
  • Cardiac: assess for presence of new murmurs or rhythm/rate disturbances
  • Abdomen: assess for palpable masses or hernias
  • Musculoskeletal: assess for developmental dysplasia of the hips ( neonate Neonate An infant during the first 28 days after birth. Physical Examination of the Newborn), appropriate strength, and range of motion Range of motion The distance and direction to which a bone joint can be extended. Range of motion is a function of the condition of the joints, muscles, and connective tissues involved. Joint flexibility can be improved through appropriate muscle strength exercises. Examination of the Upper Limbs
  • Neurologic: ensure appropriate resolution of primitive reflexes Primitive Reflexes Primitive reflexes are involuntary motor responses that can be elicited after birth. Although these reflexes are important for survival, they gradually disappear within the 1st year of life due to their inhibition by the developing frontal lobe. Primitive Reflexes
  • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions: assess coloration and check for any skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions lesions
• Height and weight:
  • Should be measured at every visit, with the same instruments if possible, and plotted on a growth chart
  • Monitoring pattern of growth along plotted curves is more important than the absolute value.
  • Significant deviations (> 2 standard deviations) from the plotted curve (change in growth patterns) are worrisome and require further evaluation.
• Head circumference Head Circumference Physical Examination of the Newborn measurement:
  • Should also be plotted and monitored on growth chart
  • Increasing head circumference Head Circumference Physical Examination of the Newborn > 97th percentile for age is a concern for hydrocephalus Hydrocephalus Excessive accumulation of cerebrospinal fluid within the cranium which may be associated with dilation of cerebral ventricles, intracranial. Subarachnoid Hemorrhage or tumor Tumor Inflammation.
  • Decreasing head circumference Head Circumference Physical Examination of the Newborn ( microcephaly Microcephaly A congenital abnormality in which the cerebrum is underdeveloped, the fontanels close prematurely, and, as a result, the head is small. (desk reference for neuroscience, 2nd ed. ). Fetal Alcohol Spectrum Disorder) < 3rd percentile for given age is a concern for possible congenital Congenital Chorioretinitis TORCH ( toxoplasmosis Toxoplasmosis Toxoplasmosis is an infectious disease caused by Toxoplasma gondii, an obligate intracellular protozoan parasite. Felines are the definitive host, but transmission to humans can occur through contact with cat feces or the consumption of contaminated foods. The clinical presentation and complications depend on the host’s immune status. Toxoplasma/Toxoplasmosis, other agents, rubella Rubella An acute infectious disease caused by the rubella virus. The virus enters the respiratory tract via airborne droplet and spreads to the lymphatic system. Rubella Virus, cytomegalovirus Cytomegalovirus CMV is a ubiquitous double-stranded DNA virus belonging to the Herpesviridae family. CMV infections can be transmitted in bodily fluids, such as blood, saliva, urine, semen, and breast milk. The initial infection is usually asymptomatic in the immunocompetent host, or it can present with symptoms of mononucleosis. Cytomegalovirus, herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections) infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Assessment of feeding/nutritional status:
  • Discuss frequency, amount, and type of feedings.
  • For breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding infants, adequacy of latch and positioning during feeds, perceived effectiveness of feeds, and concerns or challenges should be addressed at each visit.
  • Offer guidance; offer skilled breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding support services, if needed.
  • At 4–6 months, provide advice regarding transition to solid foods.
• Assessment of developmental milestones Developmental milestones Developmental milestones are the skills or abilities that most children are able to perform when they reach a certain age. Understanding the appropriate milestones and at what age they are reached helps clinicians identify symptoms of delayed development. Developmental milestones are divided into 5 important domains: gross motor, fine motor, language, social, and cognitive. Developmental Milestones and Normal Growth
• Immunizations
• Additional screenings
• Providing anticipatory guidance and counseling to parents
• Addressing any parental/caregiver concerns

Feeding and Nutrition

General feeding guidelines

• Feedings should occur on demand or approximately every 2–3 hours; 8–12 per day.
• A feeding typically lasts 20 minutes.
• Hold baby while feeding; do not prop bottle if bottle feeding.
• Do not microwave either expressed or formula milk, as this can lead to scalding due to inconsistent temperatures throughout.

Breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding

Breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding is the primary source of nutrition for infants and is recommended as the exclusive means of feeding for the 1st 6 months of life, with continuation up to 2 years of age.

Mature human milk contains necessary nutrients for infant and provides antibodies Antibodies Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions formed by the mother, protecting the baby against infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease as the immune system Immune system The body’s defense mechanism against foreign organisms or substances and deviant native cells. It includes the humoral immune response and the cell-mediated response and consists of a complex of interrelated cellular, molecular, and genetic components. Primary Lymphatic Organs develops.

Benefits to infant:

• Breast milk immunoglobulins Immunoglobulins Immunoglobulins (Igs), also known as antibodies, are glycoprotein molecules produced by plasma cells that act in immune responses by recognizing and binding particular antigens. The various Ig classes are IgG (the most abundant), IgM, IgE, IgD, and IgA, which differ in their biologic features, structure, target specificity, and distribution. Immunoglobulins: Types and Functions confer passive immunity to the infant to ↓ risk of infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease
• Improves GI function and motility Motility The motor activity of the gastrointestinal tract. Gastrointestinal Motility
• ↓ Risk of asthma Asthma Asthma is a chronic inflammatory respiratory condition characterized by bronchial hyperresponsiveness and airflow obstruction. The disease is believed to result from the complex interaction of host and environmental factors that increase disease predisposition, with inflammation causing symptoms and structural changes. Patients typically present with wheezing, cough, and dyspnea. Asthma, allergies Allergies A medical specialty concerned with the hypersensitivity of the individual to foreign substances and protection from the resultant infection or disorder. Selective IgA Deficiency, obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity, diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus, and SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS)

Benefits to mother:

• Increases maternal–baby bonding
• Faster uterine constriction
• ↓ Risk of ovarian and breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
• Faster maternal weight loss Weight loss Decrease in existing body weight. Bariatric Surgery
• Method of contraception

Breast milk storage:

• Room temperature (approximately 77°F): ≤ 4 hours
• Refrigerator: ≤ 4 days
• Freezer: 6 months best; up to 12 months acceptable

If there are challenges with breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding, expressed breast milk should be given to infant.

Breastfed infants should not be encouraged to drink formula except in the following situations:

• Breast milk production inadequate
• Infant showing signs of dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration, such as decreased urine output (may indicate inadequate milk intake)
• Contraindications Contraindications A condition or factor associated with a recipient that makes the use of a drug, procedure, or physical agent improper or inadvisable. Contraindications may be absolute (life threatening) or relative (higher risk of complications in which benefits may outweigh risks). Noninvasive Ventilation to breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding exist:
  • Maternal: certain infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease (e.g., HIV HIV Anti-HIV Drugs and TB TB Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex bacteria. The bacteria usually attack the lungs but can also damage other parts of the body. Approximately 30% of people around the world are infected with this pathogen, with the majority harboring a latent infection. Tuberculosis spreads through the air when a person with active pulmonary infection coughs or sneezes. Tuberculosis) and use of substances or medications that can be passed through the breast milk
  • Infant: certain inborn errors of metabolism (e.g., galactosemia Galactosemia Galactosemia is a disorder caused by defects in galactose metabolism. Galactosemia is an inherited, autosomal-recessive condition, which results in inadequate galactose processing and high blood levels of monosaccharide. The rare disorder often presents in infants with symptoms of lethargy, nausea, vomiting, diarrhea, and jaundice. Galactosemia, phenylketonuria)

Formula feeding

If an infant is formula-fed, it is important to discuss the type of formula used:

• Milk-based formula: most common and 1st-line choice
• Soy-based formula: also an option, but no real benefit to its use over milk-based formula
• Special hydrolyzed formulas (e.g., alimentum): may be used for those with a true milk-protein allergy Allergy An abnormal adaptive immune response that may or may not involve antigen-specific IgE Type I Hypersensitivity Reaction
• High level of cross-allergy between milk-based and soy-based formulas: if true milk allergy Allergy An abnormal adaptive immune response that may or may not involve antigen-specific IgE Type I Hypersensitivity Reaction exists, should not use soy-based formula

Appropriate mixing and ratio of powdered formula to water should be reviewed.

Additional nutritional counseling

• Supplementation
  • Vitamin D Vitamin D A vitamin that includes both cholecalciferols and ergocalciferols, which have the common effect of preventing or curing rickets in animals. It can also be viewed as a hormone since it can be formed in skin by action of ultraviolet rays upon the precursors, 7-dehydrocholesterol and ergosterol, and acts on vitamin D receptors to regulate calcium in opposition to parathyroid hormone. Fat-soluble Vitamins and their Deficiencies supplements in breastfed infants 
  • Daily iron Iron A metallic element with atomic symbol fe, atomic number 26, and atomic weight 55. 85. It is an essential constituent of hemoglobins; cytochromes; and iron-binding proteins. It plays a role in cellular redox reactions and in the transport of oxygen. Trace Elements supplements for infants < 6 months of age who were born prematurely
  • Fluoride Fluoride Inorganic salts of hydrofluoric acid, hf, in which the fluorine atom is in the -1 oxidation state. Sodium and stannous salts are commonly used in dentifrices. Trace Elements supplementation in infants ≥ 6 months of age if local water supply has inadequate fluoridation
• May start introducing solid foods gradually beginning at approximately 4–6 months of age
  • Rice cereal fortified with iron Iron A metallic element with atomic symbol fe, atomic number 26, and atomic weight 55. 85. It is an essential constituent of hemoglobins; cytochromes; and iron-binding proteins. It plays a role in cellular redox reactions and in the transport of oxygen. Trace Elements is the recommended initial weaning Weaning Techniques for effecting the transition of the respiratory-failure patient from mechanical ventilation to spontaneous ventilation, while meeting the criteria that tidal volume be above a given threshold (greater than 5 ml/kg), respiratory frequency be below a given count (less than 30 breaths/min), and oxygen partial pressure be above a given threshold (pao2 greater than 50mm hg). Weaning studies focus on finding methods to monitor and predict the outcome of mechanical ventilator weaning as well as finding ventilatory support techniques which will facilitate successful weaning. Present methods include intermittent mandatory ventilation, intermittent positive pressure ventilation, and mandatory minute volume ventilation. Invasive Mechanical Ventilation food. 
  • Only 1 new food per week should be introduced to an infant’s diet to help easily identify any potential food allergies Allergies A medical specialty concerned with the hypersensitivity of the individual to foreign substances and protection from the resultant infection or disorder. Selective IgA Deficiency.
• Do not give cow’s milk before 1 year of age.
• Honey should not be given to infants < 1 year of age because of the risk of botulism Botulism Botulism is a rare, neuroparalytic syndrome caused by Clostridium botulinum (C. botulinum). A fatal neurotoxin (botulinum toxin) is released causing varying degrees of muscle paralysis and distinct clinical syndromes. The most common types of botulism are foodborne and infant. Botulism.

Development 0–12 Months

Growth parameters Growth Parameters Child and Adolescent Care

• Weight
  • Double birth weight by 4 months 
  • Triple birth weight by 1 year 
• Length/height
  • Should increase by > 30% relative to birth length by 6 months of age
  • Should increase by approximately 50% relative to birth length by 1 year of age
• Rate of head circumference Head Circumference Physical Examination of the Newborn growth
  • Growth greatest in 1st 3 months of life (approximately 5 cm)
  • Gradually slows by 12 months of age, with rate falling to approximately 1 cm between 9 and 12 months of age
• Inadequate growth in these parameters for age ( failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive) requires further evaluation of underlying conditions:
  • Problems with feeding
  • Possible neglect Neglect Child Abuse
  • Pathologic conditions affecting nutrient absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption
  • Conditions causing excessive calorie loss

Developmental milestones Developmental milestones Developmental milestones are the skills or abilities that most children are able to perform when they reach a certain age. Understanding the appropriate milestones and at what age they are reached helps clinicians identify symptoms of delayed development. Developmental milestones are divided into 5 important domains: gross motor, fine motor, language, social, and cognitive. Developmental Milestones and Normal Growth

• Markers or milestones set at specific ages to assess for appropriate development in infants and children in the following areas:
  • Gross motor Gross Motor Developmental Milestones and Normal Growth skills
  • Fine motor Fine Motor Developmental Milestones and Normal Growth skills
  • Language development
  • Social skills
  • Cognitive skills
• Represent what is expected on average:
  • Length of time each child requires to meet milestones varies. 
  • When a child does not meet a milestone, it should be noted, but may not be of immediate concern.
  • Persistent delay or global lack of achievement of milestones longer than expected may warrant further evaluation and extra support and referrals to help the child develop abilities and skills properly.
  • In cases of developmental delay, the earlier the intervention, the better the final outcome for the child.
• Developmental red flags:
  • Primitive reflexes Primitive Reflexes Primitive reflexes are involuntary motor responses that can be elicited after birth. Although these reflexes are important for survival, they gradually disappear within the 1st year of life due to their inhibition by the developing frontal lobe. Primitive Reflexes persist > 6 months of age.
  • Predominant use of only 1 hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy (right-/left-handedness) < 12 months of age

Immunizations

• Multiple vaccinations are routinely recommended for infants.
• Combination vaccines often used to reduce the number of injections given
• Vaccines are typically administered IM or SC, except for rotavirus Rotavirus A genus of Reoviridae, causing acute gastroenteritis in birds and mammals, including humans. Transmission is horizontal and by environmental contamination. Seven species (rotaviruses A through G) are recognized. Rotavirus vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination, which is administered orally.
• If vaccinations are missed:
  • Catch-up schedules: reduced time interval needed between vaccine Vaccine Suspensions of killed or attenuated microorganisms (bacteria, viruses, fungi, protozoa), antigenic proteins, synthetic constructs, or other bio-molecular derivatives, administered for the prevention, amelioration, or treatment of infectious and other diseases. Vaccination doses
  • Do not have to start series over if it was already started

Health Screenings

• Hearing screening Screening Preoperative Care: 
  • Should be performed before discharge at birth
  • No later than 1 month of age if missed in the hospital
• Visual acuity Visual Acuity Clarity or sharpness of ocular vision or the ability of the eye to see fine details. Visual acuity depends on the functions of retina, neuronal transmission, and the interpretative ability of the brain. Normal visual acuity is expressed as 20/20 indicating that one can see at 20 feet what should normally be seen at that distance. Visual acuity can also be influenced by brightness, color, and contrast. Ophthalmic Exam screening Screening Preoperative Care: performed at least once between 3 and 5 years of age
• Iron Iron A metallic element with atomic symbol fe, atomic number 26, and atomic weight 55. 85. It is an essential constituent of hemoglobins; cytochromes; and iron-binding proteins. It plays a role in cellular redox reactions and in the transport of oxygen. Trace Elements deficiency anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview and Types:
  • Risk assessment Risk assessment The qualitative or quantitative estimation of the likelihood of adverse effects that may result from exposure to specified health hazards or from the absence of beneficial influences. Preoperative Care along with testing serum hemoglobin and hematocrit Hematocrit The volume of packed red blood cells in a blood specimen. The volume is measured by centrifugation in a tube with graduated markings, or with automated blood cell counters. It is an indicator of erythrocyte status in disease. For example, anemia shows a low value; polycythemia, a high value. Neonatal Polycythemia
  • Recommendation is to test once between 9 and 12 months of age
• Lead: Test serum lead levels in all infants.
  • Initial screen at 12 months if low risk, 6 months if high risk
  • Lead exposure can lead to permanent neurologic damage.

Acute Concerns

Caregivers should be counseled to seek further evaluation immediately if any of the following signs or symptoms occur.

• Rectal temperature > 38°C (100.4°F) in an infant < 57 days
• Rectal temperature > 38.5°C (101.3°F) in an infant ≥ 57 days 
• Decreased alertness:
  • Persistently decreased feeding
  • Lethargy Lethargy A general state of sluggishness, listless, or uninterested, with being tired, and having difficulty concentrating and doing simple tasks. It may be related to depression or drug addiction. Hyponatremia, sleeping more than usual and not easily awakened
• Absence of tears while crying (sign of dehydration Dehydration The condition that results from excessive loss of water from a living organism. Volume Depletion and Dehydration)
• No wet diapers > 6 hours
• Difficulty breathing:
  • Increased rate of respirations
  • Use of accessory muscles of breathing
  • Noisy breathing
• Changes in skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions coloration:
  • Bluish tint ( cyanosis Cyanosis A bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule. Pulmonary Examination)
  • Yellowing of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions ( jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice)
  • New rash Rash Rocky Mountain Spotted Fever
  • New bruising
• Irritability: persistently crying inconsolably
• Has a seizure
• Vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia > 24 hours, forceful/ projectile vomiting Projectile Vomiting Hypertrophic Pyloric Stenosis, or vomit that contains blood or bile Bile An emulsifying agent produced in the liver and secreted into the duodenum. Its composition includes bile acids and salts; cholesterol; and electrolytes. It aids digestion of fats in the duodenum. Gallbladder and Biliary Tract: Anatomy (green coloration)
• Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea:
  • > 8 stools in 8 hours
  • Stools contain blood, pus, or mucus.
• Nonbreastfeeding infant does not have bowel movement for > 3 days, especially if accompanied by vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia or irritability

Anticipatory Guidance and Counseling

Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep

• Always on back and avoid blankets/toys/bumpers to reduce the risk of SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS)
• Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep pattern and duration:
  • 14–17 hours/day for newborns
  • 12–15 hours/day for infants
  • Infrequent night waking by age 6 months
  • Emphasize bedtime routine

Umbilical cord Umbilical cord The flexible rope-like structure that connects a developing fetus to the placenta in mammals. The cord contains blood vessels which carry oxygen and nutrients from the mother to the fetus and waste products away from the fetus. Placenta, Umbilical Cord, and Amniotic Cavity care

• Keep stump clean and dry; use water and gauze only.
• Stump usually falls off within 2–3 weeks.
• Monitor for signs of infection: localized redness Redness Inflammation, swelling Swelling Inflammation, tenderness, odor, and/or yellowish discharge from the stump
• Bleeding may occur if stump is pulled or tugged off rather than falling off naturally.
• Sometimes a moist, pink or red lump of tissue may develop (granuloma) at the umbilicus and drain yellowish fluid.
  • Umbilical granuloma is the most common cause of an umbilical mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast.
  • Most common treatment is with silver nitrate.
  • Alternative treatment is in-office ligation Ligation Application of a ligature to tie a vessel or strangulate a part. Esophageal Atresia and Tracheoesophageal Fistula with sutures.

Diaper rash Rash Rocky Mountain Spotted Fever prevention

• Diaper rash Rash Rocky Mountain Spotted Fever typically results from irritation, bacterial infection, or yeast Yeast A general term for single-celled rounded fungi that reproduce by budding. Brewers’ and bakers’ yeasts are saccharomyces cerevisiae; therapeutic dried yeast is yeast, dried. Mycology infection.
• Watch for redness Redness Inflammation, scaliness, sores, or blisters in buttock and genital area under the diaper.
• Tips to prevent and treat diaper rash Rash Rocky Mountain Spotted Fever:
  • Keep skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions clean and dry.
  • Change diaper as soon as possible after urination or passing of stool.
  • Do not use wipes that contain alcohol or scents. 
  • Diapers should be loose, not overly tightened, to allow for airflow.
  • Place baby on towel and allow for bare bottom diaper-free time to expose skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions to air. 
  • Consider barrier ointments with zinc Zinc A metallic element of atomic number 30 and atomic weight 65. 38. It is a necessary trace element in the diet, forming an essential part of many enzymes, and playing an important role in protein synthesis and in cell division. Zinc deficiency is associated with anemia, short stature, hypogonadism, impaired wound healing, and geophagia. It is known by the symbol zn. Trace Elements oxide or petroleum jelly base.

Pacifier use

• Reduces the risk of SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS) through 6 months
• Increases the risk of otitis media and wheezing Wheezing Wheezing is an abnormal breath sound characterized by a whistling noise that can be relatively high-pitched and shrill (more common) or coarse. Wheezing is produced by the movement of air through narrowed or compressed small (intrathoracic) airways. Wheezing
• Weaning Weaning Techniques for effecting the transition of the respiratory-failure patient from mechanical ventilation to spontaneous ventilation, while meeting the criteria that tidal volume be above a given threshold (greater than 5 ml/kg), respiratory frequency be below a given count (less than 30 breaths/min), and oxygen partial pressure be above a given threshold (pao2 greater than 50mm hg). Weaning studies focus on finding methods to monitor and predict the outcome of mechanical ventilator weaning as well as finding ventilatory support techniques which will facilitate successful weaning. Present methods include intermittent mandatory ventilation, intermittent positive pressure ventilation, and mandatory minute volume ventilation. Invasive Mechanical Ventilation should start at 6 months

Infant safety

• Car-seat installation
  • Car seats should be placed in rear of the vehicle and should be rear-facing until the child is ≥ 20 lb and ≥ 1 year of age.
  • Car seat should not be placed in a seat with an airbag. 
• Keep water temperature set to < 110°F (43°C) to prevent accidental scalding.
• Remove firearms from the home.
• Keep up smoke and carbon monoxide Carbon monoxide Carbon monoxide (CO). A poisonous colorless, odorless, tasteless gas. It combines with hemoglobin to form carboxyhemoglobin, which has no oxygen carrying capacity. The resultant oxygen deprivation causes headache, dizziness, decreased pulse and respiratory rates, unconsciousness, and death. Carbon Monoxide Poisoning alarms.
• Concerns for abuse/ neglect Neglect Child Abuse: Signs on exam and a history that does not match physical findings should raise suspicion for abuse or neglect Neglect Child Abuse.
  • Multiple injuries in various stages of healing
  • Bruises in odd places in an infant who is not yet mobile
  • Patterned injuries, such as might occur with cigarette or immersion burns Burns A burn is a type of injury to the skin and deeper tissues caused by exposure to heat, electricity, chemicals, friction, or radiation. Burns are classified according to their depth as superficial (1st-degree), partial-thickness (2nd-degree), full-thickness (3rd-degree), and 4th-degree burns. Burns
  • Presence of retinal hemorrhage
  • Presence of metaphyseal “bucket handle” or “corner” fractures

Other

• 1st dental visit should occur after 1st tooth erupts or no later than 12 months of age.
• Female infants may have blood-tinged or milky-white vaginal discharge in 1st week of life, this is normal because of maternal hormonal withdrawal, but it often concerns parents.
• Recommendations for “time outs” for parents, so they do not become overwhelmed

Clinical Relevance

The following conditions are relevant to those seen in the course of providing infant care. 

• Failure to thrive Failure to Thrive Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive ( FTT FTT Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive): suboptimal weight gain Suboptimal Weight Gain Failure to Thrive and growth in a child. Causes of FTT FTT Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive may be organic or nonorganic, with the majority of cases due to inadequate caloric intake Inadequate Caloric Intake Failure to Thrive. History and physical examination guides workup, which helps uncover the underlying cause. A multidisciplinary approach is taken in the management of nonorganic causes of FTT FTT Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive, while organic causes require management of the underlying pathologic process. It is important to recognize and treat FTT FTT Failure to thrive (FTT), or faltering growth, describes suboptimal weight gain and growth in children. The majority of cases are due to inadequate caloric intake; however, genetic, infectious, and oncological etiologies are also common. Failure to Thrive in order to avoid developmental delays.
• Colic: persistent and intense paroxysmal crying and fussiness in a healthy infant for no apparent reason that tends to occur in the late afternoons or evenings. Infant cries > 3 hours a day > 3 days a week for > 3 weeks. The etiology of colic is unclear. Colic occurs most often in the 1st few months of life, with spontaneous resolution by 4 months. History and exam leads to diagnosis. Management involves parental reassurance Reassurance Clinician–Patient Relationship and soothing techniques.  
• Jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice of the newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn: may be due to indirect hyperbilirubinemia Indirect Hyperbilirubinemia Hyperbilirubinemia of the Newborn (physiologic), direct hyperbilirubinemia Direct Hyperbilirubinemia Hyperbilirubinemia of the Newborn (pathologic), or breast milk. Symptoms include worsening yellowish discoloration of the eyes and skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions. Those with pathologic jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice may have hepatomegaly, lethargy Lethargy A general state of sluggishness, listless, or uninterested, with being tired, and having difficulty concentrating and doing simple tasks. It may be related to depression or drug addiction. Hyponatremia, and poor feeding as well. Pathologic jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice often presents in the 1st 24 hours of life. Physiologic jaundice Jaundice Jaundice is the abnormal yellowing of the skin and/or sclera caused by the accumulation of bilirubin. Hyperbilirubinemia is caused by either an increase in bilirubin production or a decrease in the hepatic uptake, conjugation, or excretion of bilirubin. Jaundice presents within 36–48 hours of life and typically resolves by the 10th day of life. Breast milk jaundice Breast Milk Jaundice Breastfeeding presents in the 2nd–3rd weeks of life. Management involves UV phototherapy Phototherapy Treatment of disease by exposure to light, especially by variously concentrated light rays or specific wavelengths. Hyperbilirubinemia of the Newborn and, in severe cases, exchange transfusions. 
• Developmental dysplasia of the hip Developmental dysplasia of the hip Developmental dysplasia of the hip refers to a range of disorders of the hip joint characterized by hip instability and resulting in subluxation or dislocation that mostly presents during the first few months of life. The condition is often first recognized due to hip laxity on newborn exam. Developmental Dysplasia of the Hip: disorder of the hip joint Hip joint The hip joint is a ball-and-socket joint formed by the head of the femur and the acetabulum of the pelvis. The hip joint is the most stable joint in the body and is supported by a very strong capsule and several ligaments, allowing the joint to sustain forces that can be multiple times the total body weight. Hip Joint: Anatomy characterized by hip instability, resulting in subluxation Subluxation Radial Head Subluxation (Nursemaid’s Elbow) or dislocation of the hip. Hip laxity, decreased motion, or leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy asymmetry Asymmetry Examination of the Upper Limbs may be noted on exam. Developmental dysplasia of the hip Developmental dysplasia of the hip Developmental dysplasia of the hip refers to a range of disorders of the hip joint characterized by hip instability and resulting in subluxation or dislocation that mostly presents during the first few months of life. The condition is often first recognized due to hip laxity on newborn exam. Developmental Dysplasia of the Hip most commonly occurs in otherwise healthy girls and often does not have an identifiable cause. Imaging aids AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS in diagnosis. Treatment of infants ≤ 6 months often involves a Pavlik harness, whereas children > 6 months of age often require open or closed surgical reduction.
• Febrile illness: most commonly due to urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract: Anatomy infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease (UTIs), bacterial sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock, meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis, and pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia in infants < 2 months of age. Lethargy Lethargy A general state of sluggishness, listless, or uninterested, with being tired, and having difficulty concentrating and doing simple tasks. It may be related to depression or drug addiction. Hyponatremia and poor feeding are common. Depending on age of the infant, workup includes CBC, blood culture, urinalysis Urinalysis Examination of urine by chemical, physical, or microscopic means. Routine urinalysis usually includes performing chemical screening tests, determining specific gravity, observing any unusual color or odor, screening for bacteriuria, and examining the sediment microscopically. Urinary Tract Infections (UTIs) in Children/ urine culture Urine culture Urinary tract infections (UTIs), lumbar puncture Lumbar Puncture Febrile Infant, and x-rays X-rays X-rays are high-energy particles of electromagnetic radiation used in the medical field for the generation of anatomical images. X-rays are projected through the body of a patient and onto a film, and this technique is called conventional or projectional radiography. X-rays. Febrile infants < 30 days old are at high risk for neonatal sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock and require full workup, admission, and IV antibiotics. The younger the infant, the more extensive the workup needed. 
• Respiratory syncytial virus Respiratory Syncytial Virus Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus ( RSV RSV Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus): leading cause of bronchiolitis Bronchiolitis Inflammation of the bronchioles. Pediatric Chest Abnormalities and viral pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia in infants and young children. Respiratory syncytial virus Respiratory Syncytial Virus Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus is a frequent cause of hospitalization Hospitalization The confinement of a patient in a hospital. Delirium in infants. Infants may present with cough, wheezing Wheezing Wheezing is an abnormal breath sound characterized by a whistling noise that can be relatively high-pitched and shrill (more common) or coarse. Wheezing is produced by the movement of air through narrowed or compressed small (intrathoracic) airways. Wheezing, difficulty breathing, irritability, lethargy Lethargy A general state of sluggishness, listless, or uninterested, with being tired, and having difficulty concentrating and doing simple tasks. It may be related to depression or drug addiction. Hyponatremia, and poor feeding. Diagnosis is clinical; usefulness of nasopharyngeal PCR PCR Polymerase chain reaction (PCR) is a technique that amplifies DNA fragments exponentially for analysis. The process is highly specific, allowing for the targeting of specific genomic sequences, even with minuscule sample amounts. The PCR cycles multiple times through 3 phases: denaturation of the template DNA, annealing of a specific primer to the individual DNA strands, and synthesis/elongation of new DNA molecules. Polymerase Chain Reaction (PCR) testing and chest x-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests is questionable, but these may help confirm cases. Management is supportive, including oxygen, nasogastric tube Nasogastric tube Malnutrition in children in resource-limited countries feeding, and mechanical ventilation Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing in severe cases. 
• Croup Croup Croup, also known as laryngotracheobronchitis, is a disease most commonly caused by a viral infection that leads to severe inflammation of the upper airway. It usually presents in children < 5 years of age. Patients develop a hoarse, "seal-like" barking cough and inspiratory stridor. Croup: also known as laryngotracheobronchitis Laryngotracheobronchitis Croup, also known as laryngotracheobronchitis, is a disease most commonly caused by a viral infection that leads to severe inflammation of the upper airway. It usually presents in children < 5 years of age. Patients develop a hoarse, "seal-like" barking cough and inspiratory stridor. Croup. Croup Croup Croup, also known as laryngotracheobronchitis, is a disease most commonly caused by a viral infection that leads to severe inflammation of the upper airway. It usually presents in children < 5 years of age. Patients develop a hoarse, "seal-like" barking cough and inspiratory stridor. Croup is a common respiratory condition in infants and young children. Croup Croup Croup, also known as laryngotracheobronchitis, is a disease most commonly caused by a viral infection that leads to severe inflammation of the upper airway. It usually presents in children < 5 years of age. Patients develop a hoarse, "seal-like" barking cough and inspiratory stridor. Croup is caused by a variety of viruses Viruses Minute infectious agents whose genomes are composed of DNA or RNA, but not both. They are characterized by a lack of independent metabolism and the inability to replicate outside living host cells. Virology, the most common being parainfluenza virus Parainfluenza virus Human parainfluenza viruses (HPIVs) are single-stranded, linear, negative-sense RNA viruses of the family Paramyxoviridae and the genus Paramyxovirus. Human parainfluenza viruses are the 2nd most common cause of lower respiratory disease in children, after the respiratory syncytial virus. Parainfluenza Virus. Clinical presentation includes low-grade fever Low-Grade Fever Erythema Infectiosum, inspiratory stridor Stridor Laryngomalacia and Tracheomalacia, barking cough, and noisy or labored breathing. Diagnosis is usually made via history and exam. Management involves racemic epinephrine Epinephrine The active sympathomimetic hormone from the adrenal medulla. It stimulates both the alpha- and beta- adrenergic systems, causes systemic vasoconstriction and gastrointestinal relaxation, stimulates the heart, and dilates bronchi and cerebral vessels. Sympathomimetic Drugs and dexamethasone Dexamethasone An anti-inflammatory 9-fluoro-glucocorticoid. Antiemetics. 
• Red reflex Red Reflex Cataracts in Children abnormalities: assessing for the red reflex Red Reflex Cataracts in Children, or reflection of the eyes, is an important aspect of the infant exam for early detection of potentially vision Vision Ophthalmic Exam or life-threatening conditions such as cataracts, retinoblastoma Retinoblastoma Retinoblastoma is a rare tumor but the most common primary intraocular malignancy of childhood. It is believed that the condition arises from a neuronal progenitor cell. Retinoblastoma can be heritable or non-heritable. Retinoblastoma, or other ocular abnormalities. The red reflex Red Reflex Cataracts in Children is tested in a dark room with an ophthalmoscope Ophthalmoscope Ophthalmic Exam and should be present and symmetric in both eyes Both Eyes Refractive Errors. If the red reflex Red Reflex Cataracts in Children is asymmetric or absent or if dark or white spots are seen, referral to a pediatric ophthalmologist should be made.