The Neonatal Exam

  • General inspection
    • Responsiveness
    • Work of breathing
    • Hydration
    • Tone
    • Symmetry
    • Skin lesions
      • Capillary naevi / stork marks – faint pink lesions over face and neck
      • Milia – tiny white spots on forehead nose or cheeks
      • Sebcaeous hyperplasia – Small white to yellow papules on nose and face
  • Hands and arms
    • Erb’s palsy – the arm is flaccid by the side – brachial plexus injury in delivery – transient
    • A fractured clavicle may be detected by crepitus over the bone but does not require management
    • DigitsPalmar creases (simian crease of Down’s)
    • Tone, symmetry
    • Posture (normally flexed)
    • Palmomental reflex
  • Head and scalp
    • Caput – oedema over presenting part, resolves in a day or two
    • Cephalohaematoma – haemorrhage under periosteum, does not cross suture lines, organises from margins
    • Moulding – skull bones move to allow delivery, sutures may override but should  move separately
    • Subgaleal haemorrhage
      • Haemorrhage into the space under the galeal aponeurosis and above the periosteum
      • Rare, significant volume shifts may ensure
      • Whole scalp feels boggy and loose
    • Craniosynostosis may be indicated by a clear ridge over a suture
    • Palpate the fontanelles
  • Face
    • Facial asymmetry when crying may be due to temporary delivry-induced facial palsy
    • Rooting reflex – stroke the cheek, look for piggish behaviour
    • Palpate the oral cavity for
      • Suck
      • Cleft palate
      • Ankyloglossia
    • The Pierre Robin sequence mandates airway assessment and comprises
      • Micrognathia
      • Cleft palate
    • Natal teeth
  • Eyes
    • Subconjunctival haemorrhages are common
    • Red reflex – leucocoria may indicate retinoblastoma or congenital cataracts
  • Ears
    • Preaurical skint ags/pits are common, assess for hearing loss if found with other aural defects and first branchial arch pathology
  • Thorax
    • Heart and lung sounds
    • If doubts abour presence of femoral pulse (? coarctation), take BP in both legs
  • Abdomen
    • Umbilical hernia (common, usually self-resolving)
    • Organomegaly
    • Ttenderness is a difficult sign to elicit
  • Nappy area
    • Femoral pulses (coarctation of the aorta)
    • Symmetrical sexual organs
      • Palpate both testes together
      • Distinguish undescended testes from retractile testes by warming
    • Hypospadia
    • Hydrocoeles – transilluminate;require no action
    • Vaginal mucoid discharges / small vaginal bleed are beign and common
    • Perforate anus
  • Hips
    • Ortolani and Barlow’s (DDH)
  • Back
    • Tone (head should be extended when prone at 6 weeks)
    • Tufts of hair, pits (spina bifida)
    • Stepping reflex
    • Flip baby over and elicit the Moro reflex
  • Investigations
    • Pulse oximetry
      • Screen for congenital cyanotic CVD
      • Consider pre-ductal (upper extremities) versus post-ductal (left foot) saturations
    •  Weight, length and head circumference

Just Dentistry Things for Little People

Dental caries

  • Metabolism of sugars and starchs by mutans streptococci to produce acids
  • Lowered oral pH leading to demineralisation
  • Redposition of minerals from the saliva occurs once neutral pH is restored
  • Fluoridation is good, orhal hygeine and diet are better
  • Remineralisation proucts are just stating to come on the market

Dental abscess

  • Particular clinical features include closure of the ey in upper jaw abscess and airway compromise in the lower jaw
  • Extraction under general anaesthesia
  • Amoxycilin

Teething

  • Minor symptoms
    • Irritability
    • Dribbling
    • Flushed cheeks
  • A sick child should prompt a search for other causes

General things

  • Stop sucking dummies – leads to open bite
  • Fraenectomy can be performed for bad tongue tie
  • It’s hard to get kids into public dentistry service so we have to deal with teeth problems. Lame.

Community resources

  • School dental service
  • PMH for emergency treatment
  • OHCWA for Health Care Card holders
  • Disability Services Commissions

 

 

Common Seizures Are Common

Febrile convulsions

  • Go read a guidelines

West syndrome / infantile spasms

  • Most common epileptic syndrome in infancy
  • Brief tonic seizure that occur in series over minutes, typically multiple times a day
  • Developmental regression
  • Underlying aetiology (brain lesion, metabolic disorder etc.) in 80%
  • First line treatment is with corticosteroids

Breath-holding attacks

  • Usually onst in 1st or 2nd year, present in 4%
  • Percipitated by physical or emotional trauma (punched by a whale, anger, frustration, getting scared etc.)
  • Attacks usually commence with crying
  • Apnoea and bradycardia then ensue, followed by cyanosis and pallor
  • Syncopal jerkings may occur
  • Recovery is rapid but post-event drowsiness and confusion do not preclude the diagnosis
  • Usually ceases by age 4
  • Benign, does not need workup

Absence seizures

  • Sudden cessation of activity, staring, automatism
  • Usually <15 seconds
  • Child unresponsive
  • Falls, collapse, incontinence are rare
  • Usually not postictal
  • Major implications on academics
  • Confirm diagnosis with EEG, neuroimaging unnecessary
  • Sodium valproate, ethosuximide, lamotrigine are main options

Benign rolandic epilepsy / benign childhood epilepsy with centrotemporal spikes

  • Typically male between 5 and 10 years old
  • May begin in sleep
  • Focal seizures
    • Tingling/twitching of mouth
    • Preserved consiouness
    • Drooling
    • Choking noices
    • Inability to speak
  • Progression of focal seizures to:
    • Jerking of one side of the body
    • Impairment of consiousness may occur
  • Has characteristic EEG
  • Prognosis excellent, remission by teenage years
  • Most children only have one or two seizures
  • Anticonvulsant therapy with valproate or carbamazepine for 1-2 years may not be neccesary

Juvenile myoclonic epilepsy

  • Begins in teenage years
  • Generalised tonic-clonic
  • Early morning myoclonic jerks
  • Brief or subtle absence seizures
  • Treat with sodium valproate

 

Developmental Paediatrics Assessment

History

  • Hearing
  • Eating habits
  • Toilet habits
  • Physical activity
  • Behaviour and mood
    • Global gestalt of life at childcare
    • Changes and stressor
  • Allergies
  • Secondary smoking

Examination

  • Anthropometry + growth charts
  • Eyesight
    • VA
    • EOM
    • Ocular alignment
  • Hearing
    • Evidence of otitis
    • Consider formal hearing assessment
  • Oral health
  • Dysmorphic features

Developmental Assessment

  • Gross motor
  • Fine motor
  • Speech and language
  • Social skills
  • Emotional reaction
  • Problem solving
  • Intellectual ability
  •  Goodenough test
    • Base score of 3 and +1 point per additional detail
    • Developmental age is 3+ n/4

Developmental red flags

Birth to 3 years 3-5 years 5-8 years
Gross motor Bottom shufflingDelayed walkingNot climbing/fear of climbing Delaye or awkward runningNot pedalling a tricycleBumping into objects

Excessive falling

Not hopping

Not skipping (>6y.o.)Inability to throw, catch or kick a ballInability to ride a bike

Tripping over or falling

Not being picked for team activities

Fine motor Delayed pincer grip (>10/12)Not stacking blocksAvoiding form boards and constructional toys

Avoiding pencil tasks (>2 y.o.)

Difficulties cutting or threadingAvoiding puzzles and constructional toysDifficulties with dressing and buttons

Finger feeding rather than using utensils

Avoiding drawing or immature drawingInability to colour in shapesInability to do up shoelaces

Messy or illegible handwriting

Low output of written work

Speech and language Absence of single words (18/12)No interest in booksReduced imaginative play (>2 y.o) Not using developed simple  sentences (by 2.5 y.o.)Speech unclear to strangersUse of gestures or mime more than words (by 3.5) Unclear or limited sentencesSpeech unclear to familyNo interest in books or stories

Delay in reading and spelling

Behavioural and social Unsettled or sleeping poorlyIrritabilityExcessive tantrums after 2 y.o. Unsettled sleepPersistent tantrumsInability to play with peers

Inability to self-dress and unawareness of toileting skills

Difficulty making friendsEmotional labilityDelayed dressing and feeding skils

Reluctance or refusal to attend school

 

Indications for autism spectrum disorder evaluation

  • Any age
    • Regression of language
    • Persistent mutism
    • Speech not related to topic
  • 12/12 – no gesturing, not turning to name
  • 16/12 – no single words
  • 18/12 – not pointing with index
  • 24/12 – no-word spontaneous phrases
  • Older children
    • Failure to answer
    • Poor conversation
    • Echolalia
    • Pronoun misuse
    • Poor narration
    • Perserveration
    • Idiosyncratic speech

Investigations

  1. FBC
  2. CRP (occult autoimmune/infection state)
  3. TFT
  4. Audiolometry
  5. Opthalmology screen
  6. Genetic studies
    1. Karyotype
    2. Fragile X PCR
    3. FISH probes
  7. Metabolic screen
    1. Glucose
    2. UEC
    3. LFT
    4. Ammonia

 

 

Approach to Developmental Delay

So….this is kinda my take on how to approach little Timmy who isn’t doing too well at school.

It may or may not be wrong in the extreme. You pays your moneys and you takes your chances.

And yes, i am aware autism isn’t a GDD condition – I put it there in the flowchart because the GDD group of consitions are often the major differentials for autism spectrum disorders. Also, I’m too lazy to modify the flowchart. So there.

Links to specific posts below:

View a larger version of the below chart here

Maybe it works. Dunno.

Approach to Developmental Paediatrics

Hypoxic Ischaemic Encephalopathy

Precipitant

  • Acidemia with pH <7 on umbilical artery sample
  • Apgar 0-3 for more than 5 minutes
  • Neurological sequelae in the neonate
  • Multiple organ involvement

Examination

  • Mild
    • Mild hypertonia, hyperreflexia
    • Transient behavioural abnormalities
      • Feeding
      • Irritability
      • Excessive crying or sleepiness, typically alternating
    • Usually resolves in 24 hours
    • May also degenerate reflecting ongoijg brain injury
  • Moderate
    • Lethargy
    • HYPOtonia and HYPOreflexia
    • Sluggish or absent primitive reflexes
    • Apnoea
    • Seizures within 24 hours
    • May fully resolve by 2 weeks
  • Severe
    • Stupor or coma
    • Irregular breathing, ventilatory support may be required
    • Generalised hypotonia
    • Absent reflexes
    • Skewed deviation of eyes, nystagmus, loss of doll’s eye movements
    • Fixed (or sluggish), blown pupil
    • Seizures
    • Haemodynamic irregularity

Management

  • Resuscitate
  • Aim for therapeutic hypothermia
  • Consider permissive hypercapnia

Group B Strep and the Neonate

Recognition of the sick neonate

  • Increased work of breathing
  • Apnoeic episodes
  • Lethargy
  • Poor feeding
  • Evidence of haemodynamic instability / poor perfusion

Workup

  • Full workup
    • FBC
    • CRP
    • Gastric aspirate M/C/S correlates well with amniotic fluid culture
    • Blood culture
    • Ear swab
    • Consider LP and CXR
  • Perform full workup if
    • Maternal GBS status unknow and neonatal signs of sepsis
    • Maternal temperature >38
    • Maternal chorioamnionitis
    • Previous obstetric history of GBS disease
  • Perform limited septic screen if
    • Mother GBS positive and intrapartum Abx >4 hours before delivery

Management

  • BenPen + Gent if
    • Maternal GBS status unknow and neonatal signs of sepsis
    • Maternal temperature >38
    • Maternal chorioamnionitis
    • Previous obstetric history of GBS disease
  • Observe 24-48 hours if
    • Mother GBS positive and intrapartum Abx >4 hours before delivery
  • FBP + CRP and repeat 12 hourly if:
    • Mother GBS positive and IAP <4 hours before delivery
    • Prematurity
    • PROM  > 18 hours