Basic Pediatrics Notes: part 2

The Respiratory Tract

Movement of the fetal chest, 40-70 per minute is present about 70% of the time during the
last half of gestation

Breathing detected sporadically as early as 13 wks of gestation; reflex gasping as early as
11-12 wks

Diminished movements with hypoxia or hypoglycemia

Newborn infants
Obligate nasal breathers
Do not breath through their mouths resort to gavage feeding not NGT
Choanal atresia may be life threatening

1st year
Nasal obstruction with congestion common
Intranasal airway double in size at 6 mos

Right primary bronchus larger than the left and at a more acute angle

Dimensions of the larynx (and trachea) at birth one third than that of the adult

Cavity is short and funnel shaped throughout infancy

Rapid growth until 2-3 yrs then slower increment until puberty

The Respiratory Tract

Foreign bodies are often placed in the nose by small children and constitute less than 1%
of pediatric emergency department visits

Initial symptoms are unilateral obstruction, sneezing, discomfort, and rarely pain

The Respiratory Tract

Clinical symptoms include mucopurulent nasal discharge, foul nasal odor, epistaxis, nasal
obstruction, mouth breathing.

Trachea in the newborn is about 4cm long, one third the adult length small lumen =
respiratory difficulty

Airways grow predominantly antenatally but the alveoli develop after birth, increasing in
number until 8 years and in size until the chest wall ceases growing as an adult

Little change in the topography of the lungs, fissures or pleura from infancy to maturity.

The most important stimulus to the onset of breathing is anoxia

The true stimulus to breathing is the fall in ph brought about by the accumulation of acid
metabolites
Respiration in infants is largely diaphragmatic until the 5th to 7th yr of life

Rate and depth of breathing extremely

Breathing rates

Newborn 30-80 breaths / min
1 yr 20-40 (50-70 pneumonia blowing off too much CO2 respiratory fatigue)
2 yr 20-30
5 yr 20-25
10 yr 17-22
20 yr 15-20

Gastrointestinal Tract

Epstein pearls
Pearl like glistening white structures found usually on the hard palate. Embryonic
remnant go away after a couple of days. Not significant.
Petechiae
Because of increased intrathoracic pressure especially if normal or vaginal delivery.
Compressed structures. Blood vessels ruptures - appears as petechiae. Dont
mistake for blood dyscrasia.
Natal teeth
Teeth usu erupt at 6 mos. no clinical significance. Would cause pain on the nipple of
the mother on breast feeding. If firmly embedded dont remove. If not, remove it.

Dentition

Baby teeth usu erupt as follows:
Central incisors 6-12 mos
Lateral incisors 9-14 mos
Canine (eye teeth) 16-22 mos
First year molar 13-17 mos
Second year molar 24-30 mos

Infant who don't develop tooth at 13 month monitor - hypothyroidism, or familial. Identify
failure of eruption.
Cut / eruption of first molar painful - fever, diarrhea, irritable. Bite into anything to ease the
pain, these things contain viruses which would caused the diarrhea.

Drooling

Prominent about by 3rd month.
3rd to 6th month a lot of drooling.
Increases with the eruption of the first teeth.
A protruding tongue may accentuate the condition.
Drooling is fine til 18 month. If still persistent, observe can be a sign of mental
retardation.

Gastro-esophageal reflux
 Differentiated from a vommit. Vommit is forceful. Spit is not.
Smells a little bit sour. Reason: gastroesophageal sphincter is lax not developed 1st
year. Milk gets out from that loose sphincter and comes out from the mouth.
If it becomes voluminous, it can lead to erosions, esophageal bleeding.

Gastric capacity

Birth 30-90 ml
1 mo 90-150 threefold increase
1 yr 210-360ml
2 yrs 500 ml usual gastric capacity.
Later childhood 750-900 mL
We should know gastric capacity, to avoid overfeeding. To avoid vommiting, reflux.
In the history ask for the feeding schedule.

Growth of the stomach is most rapid between birth and the 3rd month of life

Gas bubble visualized in the stomach with the 1st cry

2 hours Ileum
3-4 hours Rectum
None present in the sigmoid by 24 hours = obstruction
Double bubble sign in xray - doudenal atresia
Hallmarks of intestinal obstruction: absence of meconium, vomiting, distention

Birth = lower intestines is filled with meconium. Greenish to blackish, mucoid, 1-3 days.

Normal infant passes fecal material by 24 hrs (69% by 12 hours and 94% before 24 hours)
Fetus stress in utero, brain open sphincter, passes out meconium in utero. Can be a
problem if it obstruct respiratory passages. Suction meconium nostrils, and on mouth after
passage. So to avoid meconium aspiration syndrome causes death, morbidity and
mortality.

Stools most numerous between 3-6 days, mean average of 5 per 24 hrs.
Make sure anus is patent.

4th -7th day - transitional stools
Thin, sour, slimy, brown to green.
Homogenous, sour, pasty, yellow. Breast fed babies.

More Formed, darker stools by 2 years.

URINARY SYSTEM

Growth of the kidneys slow early in prenatal life.

Extracellular fluid volume of the newborn infant is nearly double that of the adult (40% of
body weight)
High extracellular fluid than adults. Thats why they easily dehydrate.

Lowered GFR during the 1st 9th month of life

GFR is only 30-50% that of the adult and does not reach normal adult levels until in the
late 1st yr.

Small amount of urine are usually found in the bladder at birth, the newborn may not void
for 12-24
No infant is discharged who didnt void for at least 2 days.

Protein content to protect kidney.

Genital organs

8th month - attached to the fundus of the scrotum - in utero
Can be able to palpate the testes

96% of testes were found in the scrotum at birth in fully mature male infants; only 70%
were descended in the prematurely born.

In both terms and preterm infants, 50% of the undescended gonads did come down into
the scrotum by the end of the 1st month of life
Testicular carcinoma, infertility higher risk of undescended. Surgical correction has
to be done if not descended.

Newborn vagina bleeding - physiologic
Hormones go down. Maternal transfer of hormone high, but if cord is cut no more
hormones.

FACTORS THAT AFFECT PRENATAL GROWTH AND DEVELOPMENT

Congenital defects

3% environmental factors
25% purely genetic in origin
25% multifactorial (genetic and environment)
40% unknown cause

Genetic

Single gene or mendelian disorders
Inheritance of a recessive allele from each parent. PKU, tay-sachs, sickle cell anemia
Dominant allele inheritance. Huntington's

Chromosomal abnormalities
- errors in meiosis = incorrect or damaged chromosomes in egg or sperm
- 90% of fertilized eggs with chromosomal abnormalities, are miscarried; 1/160 newborns
Down syndrome - trisomy 21, translocation, easily recognized. 90% of cases extra
chromosome comes from the mother, 10% father.

Cri-du-chat
Cat cry syndrome
Deletion in chromosome 5

Affected children have a cat-like high pitched cry during infancy, mental retardation and
physical abnormalities.

Klinefelter syndrome

Sex chromosome abnormality
1 in 500 to 1000 boys
Two or occasionally more X chromosomes along with their Y chromosomes
Affected boys usually have normal intelligence, although they may have learning
disabilities
Adults have less testosterone

Environmental factors

Age of the mother

The older the mother, the greater the incidence of anomalies of the CNS, Down syndrome,
mental subnormality, premature labor, dizygotic twins

Down syndrome
(incidence per mother's age)

Under 30 1 in 1000
30 1 in 900
35 1 in 400
36 1 in 300
37 1 in 230
38 1 in 180
39 1 in 135
40 1 in 105
42 1 in 60
44 1 in 35
46 1 in 20
48 1 in 16
49 1 in 12

Age of the father

Advanced paternal age is associated with an increase incidence of Achondroplasia,
Apert's syndrome, Down's syndrome, osteogenesis imperfecta, CHD, congenital deafness.

Maternal stress

Increased production of adrenaline, altered blood flow, changes in the mother's body
chemistry
Can produce congenital defects

Abnormal uterine and placental conditions

Intrauterine growth retardation
Fetus don't grow due to myoma
Preterm delivery
Malformation like talipes, hip dislocation, torticollis, facial palsy

Multiple pregnancy

Higher incidence of mental retardation, cerebral palsy, and other abnormalities
2nd twin more susceptible to hypoxia and birth trauma

Post maturity

Placental insufficiency
Fetal distress, hypoxia, abnormal neurological signs
Higher morbidity in the 1st year

Cerebral palsy risk increases past the gestational age of 41-42 wks

TERATOGENS
Substances in the environment that can cause abnormalities during prenatal development

Radiation
Between weeks 2 and 18 of pregnancy
Embryonic period - organ development
Stunted growth, deformities, abnormal brain function, or cancer that may develop
sometime later in life

Alcohol
Heavy drinkers 1 in 6 chance of stillbirth and 1 in 2 chance of delivering child with birth
defect
More hazardous in binge drinkers, those who drink early in pregnancy.

Tobacco
Raises carbon monoxide, vasoconstrict blood vessels
May cause prematurity, LBW 10 or more cigarettes per day
10 or more cigs per day
Significant impact on child intellectual performance at age 4

Smoking
Increased risk of cleft lip or palate
May be a factor in learning disorders and overactivity

By the farther in pregnancy = risk of lowered birthweight

DISEASES

Rubella
Blindness, deafness, mental retardation, and heart defects

Probability of birth defects
60% third or fourth week of conception
25% second month
8% third month

Endocrine Disorders
Diabetes mellitus
More insulin in infant, resulting to bigger babies. Can lead to medical emergency in
delivery, hypoglycemia due to high insulin. Can lead to death of neurons.
Hypothyroidism
Can be passed in developing fetus. Mental retardation and physical growth. Leads
to cretinism.
Newborn screening detects hypothyroidism.

- john paul bagos