PEDIATRICS*1!

Keep$Calm,$Study$Hard,$and$Goodluck!$$

!
BY:!TRISTAN!PAULO!MADRIGAL!
C2!–!BATCH!2017!
UNIVERSITY$OF$SANTO$TOMAS$
FACULTY$OF$MEDICINE$AND$SURGERY$

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 PEDIATRIC%HISTORY%AND%PHYSICAL%EXAMINATION%
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NEONATAL%HISTORY% Vital%Signs%
Gestational/%Maternal%History% o Pulse/cardiac!rate:!120B160!bpm!
o Mother’s! general! data:! Mother’s! &! father’s! name,! age,! o Respiratory!rate:!30B60!breaths/min!
gravidity! &! parity! (G1P0),! race,! birthplace,! present! o Blood! pressure:! 60B80! mmHg! systolic! pressure! (Not!
address,! religion,! educational! attainment,! nutritional! routinely!taken!unless!the!baby!is!ill!or!with!heart!murmur;!
status,! state! of! health,! illnesses! before! &! during! done!by!flush!method!using!neonatal!cuff)!
pregnancy,!familial!diseases,!infections,!prenatal!checkBup,! !
intake! of! drugs/! alchohol,! smoking,! roentgen! exposure,! General%appearance%
familial!diseases,!outcome!of!previous!pregnancy,!duration! o Posture!(Flexion)!
of!gestation! o Physical!activity!
% o Edema!
Perinatal%History% o Muscle!tone!–!should!not!be!hypotonic/limp!
o Hours!of!labor! o Level!of!alertness!(18B20!hours!sleep)!
o Start!of!regular!uterine!contractions! o Color! [cyanotic,! acrocyanotic,! pallor,! plethoric,! jaundice!
o Rupture!of!bag!of!water! (beyond!48!hours!is!physiologic)]!
o Hours!of!delivery!of!the!baby!&!placenta! !
o Obstetrical!blood!loss! Skin%
o Fetal!heart!tone!characteristic! o Vasomotor!instability:!
o Manner!of!delivery! • Mottling!due!to!temperature!adaptations!
o Person!who!assisted!the!delivery! • Acrocyanosis! (blue! discoloration,! coldness,! sweating!
% of!extremities,!especially!hands)!
Neonatal%History% • Harlequin!color!change!(vertical!splitting!of!color)!
o Presenting!part!upon!delivery! o Cyanosis!
o Spontaneous!respiration!or!required!resuscitation! o Pallor!
o APGAR!score! o Plethora:! beefy! red! coloration! of! a! newborn;! “boiled!
o Presence! of! cyanosis,! pallor,! jaundice,! convulsions,! lobster”! hue! of! the! infant’s! skin! caused! by! an! unusually!
hemorrhage! high!proportion!of!erythrocytes!per!volume!of!blood!
o Abnormal!physical!examination!findings! o Jaundice!or!icterus!
o Type!of!feeding! o Vernix! caseosa:! Grayish! white! cheeselike! substance,!
o How!long!did!the!baby!stayed!in!the!nursery/!NICU! consisting! of! sebaceous! gland! secretions,! lanugo! &!
o Any!use!of!antibiotics! desquamated!epithelial!cells!that!cover!the!fetus!skin!
o Hepatitis!B!vaccine!given!at!birth! o Erythema! toxicum! (eosinophils):! Pink! popular! rash!
o Newborn/!Hearing!screening!done% frequently! superimposed! with! vesicles! or! pustule;! rash!
% appears! within! 24B48! hours! after! birth! &! disappear!
Neonatal%History%should% spontaneously!after!several!days!
1. Identify! disabling! diseases! that! are! amenable! to! prompt! o Pustular!melanosis!(neutrophils)!
preventive!action!or!treatment!(e.g.!RDS)! o Milia:! Nonpathologic! dermatological! condition!
2. Anticipate! condition! that! maybe! of! late! importance! (e.g.! characterized! by! minute! epidermal! cysts! containing!
gonococcal!conjunctivitis)! keratinous! debris! that! occur! on! the! face! occasionally! on!
3. Uncovers! possible! causative! factors! that! may! explain! the!trunk!of!the!newborn!
pathologic!conditions!regardless!of!their!immediate!future! o Milaria:!Minute!vesicles!&!papules!often!with!surrounding!
significance!(e.g.!metabolic!diseases)% erythema,!caused!by!occlusion!of!sweat!ducts!during!times!
% of!exposure!to!heat!&!high!humidity!
PHYSICAL%EXAMINATION%OF%THE%NEWBORN%INFANT% o Mongolian! spots:! Benign! bluishBblack! macule,! between! 2!
Three%periods%of%examination% &! 8! cm,! occurring! over! the! sacrum! &! on! the! buttocks! of!
1. Immediately! after! delivery! (focus! on! congenital! problems! some! newborns.! It! usually! disappears! during! early!
&!adaptation!to!extra!uterine!life,!birth!injuries)! childhood!
2. At!24!hours!of!life!(more!detailed!examination)! o Capillary! hemangioma:! A! bloodBfilled! birthmark! or! benign!
3. Upon!discharge!(If!possible!together!with!the!mother)! tumor! consisting! of! closely! packed! small! blood! vessels,!
! commonly! found! during! infancy.! It! first! grows,! them! may!
Anthropometric%measurements% spontaneously! disappear! in! early! childhood! without!
o Birth!weight!–!3.4!kg!(boys!are!generally!heavier!than!girls)! treatment!
o Birth!length!–!50!cm! o Meconium!staining!of!skin,!cord!&!nails!
o Head!circumference!–!35!cm!! o Lanugo!(preterm)!and!Vellus!hair!(term)’!
o Chest! circumference! –! HC! is! 1B2! cm! larger! than! chest! o Gelatinous! skin! (preterm)! and! ParchmentBlike!
circumference;!After!1!year,!CC!should!be!greater!than!HC! skin!(postBterm)!
o Abdominal!circumference! o Tuft!of!hair!
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o Amniotic! band:! secondary! to! rupture! of! the! amniotic! o Chemical!irritation!
membrane!! o White!sclerae!
o Stork’s!bite:!nevi!complex!around!the!neck! o Blue!sclerae!(osteogenesis!imperfecta)!
o Pigmented!nevi! o Chorioretinitis:!An!inflammatory!condition!of!the!choroids!
o Petechiae/!purpura! &! retina! of! the! eye,! usually! as! a! result! of! a! parasitic! or!
! bacterial!infection!
Head/%skull% !
o Molding:! The! natural! process! by! which! a! baby’s! head! is! Ears%
shaped! during! labor! as! it! is! squeezed! into! &! through! the! o Anotia! (TreacherBCollin’s! syndrome):! Congenital! absence!
birth! passage! by! the! forces! of! labor;! the! head! often! of!one!or!both!ears!
becomes!elongated!&!the!bones!of!the!skull!maybe!caused! o Microtia!
to! overlap! slightly! at! the! suture! lines.! Usually! resolved! o Preauricular!tags!&!pits!
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during!the!1 !few!days!of!life! o Dull!gray!tympanic!membrane!
o Cephalhematoma! (10B20%! may! have! skull! fractures):! o Low!set!ears!and!malformed!ears!
superiosteal! hemorrhage! with! no! scalp! discoloration! that! %
does! not! cross! suture! lines;! firm! and! tense;! usually! Nose!
resorbed!within!2!weeks!to!3!months! o Broad!in!appearance!
o Caput!succedaneum:!A!localized!pitting!edema!in!the!scalp! o Choanal! atresia:! Congenital! anomaly! in! which! a! bony! or!
of!a!fetus!that!crosses!suture!lines!of!the!skull.!It!is!usually! membranous! occlusion! blocks! the! passageway! between!
formed!during!labor!as!a!result!of!the!circular!pressure!of! the!nose!&!pharynx;!characterized!by!the!inability!to!pass!
the! cervix! on! the! fetal! occiput! ;! resorbed! within! the! first! a!catheter!
week!of!life! o Flaring!of!the!ala!nasi!
o Skull!defects!(anencephaly)! !
o Anterior!&!posterior!fontanels! Mouth%
o Craniosynostosis:! Premature! ossification! of! the! sutures! of! o Natal!teeth!(lower!incisors)!
the! skull! often! associated! with! other! skeletal! defects;! the! o Bifid!uvula!
sutures! close! before! or! soon! after! birth! without! surgical! o Cleft!lip!&!palate!
correction,!the!growth!of!the!skull!is!inhibited,!the!head!is! o Sucking!pads!
deformed&!the!eyes!&!brain!are!often!damaged! o Small!tonsils!
o Craniotabes:!Benign!congenital!thinness!of!the!top!&!back! o HighBarched!palate!
of!the!skull!of!a!newborn.!Because!the!rate!of!brain!growth! o Large!tongue!
exceeds!the!rate!of!ossification!of!the!skull!during!the!last! o Ankyloglossia:!A!severe!restriction!of!tongue!movement!as!
month!of!gestation! a!result!of!adhesion!or!fusion!of!the!tongue!to!the!floor!of!
o Microcephaly:! Congenital! anomaly! characterized! by! the!mouth!
abnormal! smallness! of! head! in! relation! to! the! rest! of! the! o Retention!cysts!(ranula):!Large!mucocele!in!the!floor!of!the!
body! &! by! underdevelopment! of! the! brain! resulting! in! mouth! caused! by! destruction! of! the! ducts! of! the! salivary!
some!degree!of!mental!retardation! glands!
o Macrocephaly:! Congenital! anomaly! characterized! by! o Epstein’s!pearls:!Small!whiteBpearlBlike!epithelial!cysts!that!
abnormally!largeness!of!the!head!&!brain!in!relation!to!the! occur!on!both!sides!of!the!midline!of!the!hard!palate!of!the!
rest!of!the!body! newborn!
o Hydrocephaly:! Pathologic! condition! characterized! by! o Micrognathia! (PierreBRobin! syndrome):!
abnormal! accumulation! of! CSF,! usually! under! increased! Underdevelopment!of!the!jaw,!especially!the!mandible!
pressure,! within! the! cranial! vault! &! subsequent! dilatation! o Excessive!salivation!
of!the!ventricles! o Macrostomia!
o Cutis!aplasia!congenital! !
o Bruits! Neck%
! o Short!neck!
Face% o Hematoma!on!sternocleidomastoid!muscle!
o Dysmorphic!features:!epicanthal!folds,!widely!spaced!eyes,! o Branchial!cleft!cysts!
microphthalmia,!asymmetry,!long!philtrum,!low!set!ears! o Thyroglossal!duct!cyst!
th
o Asymmetrical!face!(7 !CN!palsy)! o Webbing:!Skinfolds!connecting!adjacent!structures!such!as!
th
o Moebius!syndrome:!Hypoplasia!of!the!7 !nerve!nucleus)! fingers! or! toes! as! the! neck! from! the! acromion! to! the!
! mastoid,!associated!with!genetic!abnormalities!
Eyes% o Resistant!neck!to!flexion!(meningitis!or!SAH)!
o Doll’s! eye! maneuver:! A! normal! response! in! newborns! to! o Bruits!of!thyroid!gland!
keep!the!eye!stationary!as!the!head!is!moved!to!the!right! o Congenital!torticollis:!An!abnormal!condition!in!which!the!
or!left.!Reflex!disappears!as!ocular!fixation!develops! head!is!inclined!
o Subconjunctival/!retinal!hemorrhages! o Clavicular! fracture! in! LGA! babies! (large! for!
o Red!orange!reflex!–!normal!finding! gestational!age)!
o Leucokoria!(white!pupillary!reflex):!condition!characterized! !
by!appearance!of!a!whitish!reflex!or!mass!in!the!papillary! ! TP
area!behind!the!lens!caused!by!cataracts,!tumors,!ROP! !
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Thorax%&%Lungs% o Undescended!testes!
Chest! o Large!labia!majora!
o Breast!hypertrophy!with!or!without!milk!(Witches’!milk)! o Hymenal! tags:! Normal! redundant! hymenal! tissue!
o Mastitis:!Inflammation!condition!of!the!breast!common!in! protruding! from! the! floor! of! the! vagina! during! the! first!
lactation!characterized!by!pain,!swelling!&!redness! weeks!of!birth!
o Supernumerary!nipples! o Testicular!torsion!
o Inverted!nipples! %
o Widespread!nipples! Anus%
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o Chest!circumference:!2!cm!<!HC! o Passage!of!meconium!within!the!1 !12!hours!after!birth!
! o Imperforate!anus!
Lungs! o Fistula!in!ano!
o Breathing!is!predominantly!abdominal! o Meconium!pearls!
o Retractions,!grunting! !
o Asymmetric!breathing! Musculoskeletal%system%
o Stridor:! Abnormal,! highBpitched! sounds! caused! by! an! o Unequal!limbs!due!to!lymphangiomas!(A!benign!yellowish!
obstruction! in! lungs! or! trachea! usually! heard! during! tan! tumor! on! the! skin! composed! of! a! mass! of! dialted!
inspiration,!may!indicate!glottic!edema,!asthma,!diptheria! lymph!vessels)!
o Bronchovesicular!breath!sounds! o Hemangiomas!
o Apnea! o Syndactyly:!fusion!of!the!fingers/!toes!
o Periodic!breathing! o Polydactyly:! presence! of! more! than! normal! number! of!
o Crackles!or!rales! fingers!or!toes!
! o Clinodactyly:!abnormal!lateral!or!medial!bending!of!one!or!
Cardiovascular%system% more!fingers!or!toes!
o Normal!resting!heart!rate:!90B160!bpm! o Ortolani!and!Barlow!maneuver:!Congenital!hip!dislocation!
th
o PMI!at!4 !ICS! (Barlow!–!adduct;!Ortolani!–!abduct)!
o Characteristic!of!pulses:!Coarctation!of!aorta! o Talipes!equinovarus/!equinovalgus!(equinovarus!–!pointing!
o Dextrocardia:! Location! of! the! heart! in! the! right! inside;!equinovalgus!–!pointing!outside)!
hemithorax,! either! as! a! result! of! displacement! or! as! a! o Amelia!(Absence!of!one!or!more!limbs)/!pocomelia:!usually!
congenital!defect! due!to!intake!of!thalidomide!during!pregnancy!
o Benign/!pathologic!murmur! o RockerBbottom!feet:!usually!seen!in!Edward’s!syndrome!
o Sinus!bradycardia! o Edema!of!feet:!usually!seen!in!Turner’s!syndrome!
o Blood! pressure:! Systolic! 40B80! mmHg,! Diastolic! 20B55! o Simian! crease:! Single! crease! across! the! palm! produced!
mmHg,!mean!25B60!mmHg! from! the! fusion! of! proximal! &! distal! palmar! creases!
! evident!in!children!with!Down’s!syndrome!
Abdomen% o Breech! presentation:! Intrauterine! position! of! the! fetus! in!
o Liver!palpable!2!cm!BRCM! which!the!buttocks!or!feet!present;!usually!resolves!on!its!
o Palpable!splenic!tip! own!
o Gas!in!rectum!by!24!hours! !
o Umbilical!hernia! %
o Masses! %
o Scaphoid!abdomen:!diaphragmatic!hernia! %
o Omphalocoele! (Congenital! herniation! of! intraabdominal! %
viscera! thru! a! defect! in! the! abdominal! wall! around! %
umbilicus),!gastroschisis! %
o Omphalitis:! Inflammation! of! umbilical! stump! marked! by! %
redness,!swelling!&!purulent!exudates!in!severe!cases! %
o Umbilical!cord:!2!arteries,!1!vein,!Wharton’s!jelly! %
o Tufts!of!hair! %
! %
Genitourinary%system% %
o Penis!should!at!least!be!2!cm!in!length! %
o Transitory!hydrocoele:!Accumulation!of!fluid!in!any!saclike! %
cavity! or! duct! specifically! in! the! tunica! vaginalis! testis! or! %
along!the!spermatic!cord! %
o Hypospadias:! Developmental! anomaly! in! male! which! the! %
urethra! opens! on! the! underside! of! the! penis! or! on! %
perineum! %
o Tight!prepuce! %
o Ambiguous!genitalia!(CAH)! %
o Pseudomenses! %
o Erection!of!the!penis! % TP
o Voiding!within!24!hours! %
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NEUROLOGICAL%EXAMINATION%OF%THE%INFANT% Cranial%Nerve%Examination%
General%considerations% o Cranial!Nerve!1!
o The!following!reflect!the!neurologic!status!of!the!baby! B Infrequently!tested!
! Posture! B Pleasant,!aromatic!substances!
! Sleep!state! B The! newborn! manifests! arrest! of! activity! &! sucking!
! Feeding! activity!
! Breathing! o Cranial!Nerves!2,!3,!4,!6,!8!
! Cardiac!status! B Assessment!of!the!eyes!
o The!optimal!time!to!do!NE!is!usually!immediately!prior!to! B Bilateral! symmetric! pupils! (response! to! light! by!
feeding!–!awake!&!responsive! blinking)!
! B Ptosis:!abnormality!of!CN!3!
Observation%of%the%infant% B GrayishBwhite!optic!disc!
o At!term!the!infant!remains!alert!for!reasonable!periods!of! B Eyes!fix!on!bright!object!&!face!
time!&!responds!to!visual,!auditory!&!tactile!stimuli! B Presence!of!visual!threat!
o Presence!of!congenital!anomalies!–!neural!tube!defects! B Observe! conjugate! eye! movements! on! Doll’s! eye!
o Look!for!neurocutaneous!lesions!–!café!au!lait!spots,!nevus! maneuver!
o Observe!respiratory!movements! o Cranial!Nerve!5!
% B Test!for!the!corneal!reflex!by!blowing!air!towards!the!
Developmental%reflexes% eyes!
o Primitive! reflexes! which! reflect! the! integrity! of! the! B Observe!for!symmetrical!closure!of!the!eyelids!
brainstem!&!spinal!cord! o Cranial!Nerve!7!
• Moro!reflex! B Facial!movements!are!readily!observed!during!crying!
• Tonic!neck!reflex! B Observe!for!symmetry!
• Grasp!reflex! o Cranial!Nerve!11!
• Placing!reflex! B Observed! by! turning! the! infant’s! head! to! one! side!
• Stepping!reflex! while!restraining!it!at!the!opposite!shoulder!
o These! reflexes! are! present! at! birth! &! disappear! by! 6! B Observe! contraction! of! the! sternocleidomastoid!
months! muscle!
o Persistence:!maturational!lag!or!impaired!CNS!function! o Cranial!Nerves!9,!10,!12!
o Asymmetry:!CNS!or!PNS!dysfunction! B Assess!the!quality!of!sucking!&!swallowing!as!well!as!
o Parachute!reflex:!not!considered!a!primitive!reflex!since!it! the!quality!of!the!voice!during!cyring!
usually!develops!at!8B12!months!and!it!will!not!disappear! !
! Sensory%testing%
Motor%function% o Tests! for! pain! &! sensation! are! imprecise! in! this! period,! &!
o Evaluate!the!posture!&!tone! the! gross! response! of! infants! to! stroking! &! pinprick! with!
o Gentle! manipulation! of! the! infant’s! limb! allows! for! withdrawal,! crying! &! changes! in! sucking! rates! maybe! the!
assessment!of!muscle!tone!&!strength! only!information!possible!
o The! baby! should! be! supine! with! the! head! in! midposition! !
while!tone!is!evaluated!so!that!the!tonic!neck!reflex!does! !
not!augment!tone!unilaterally!! !
o Posture! !
• There! is! hypertonia! of! the! elbow,! hip! &! knee!
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flexors!during!the!1 !three!months!
• Flexion!
• The! newborn! should! be! gently! held! in! the!
horizontal! position! &! at! vertical! suspension! to!
determine!if!flexor!tone!is!present!&!symmetric!
o Tone!
• Involves!examination!of!passive!&!active!tone!
• Passive! tone! is! evaluated! by! determining! the!
degree! of! resistance! to! passive! movements! of!
the!joints!
• The! active! tone! is! evaluated! by! observing! the!
baby’s!response!to!gentle!pulling!from!supine!to!
the!prone!position!(traction!response)!
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 PHYSIOLOGIC%CHANGES%IN%THE%NEWBORN%AND%HIGH%RISK%INFANTS%
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TEN%PHYSIOLOGIC%CHANGES%IN%THE%NEWBORN% COMMON%CLINICAL%PROBLEMS%IN%THE%NEWBORN%
1. Weight%Loss% 1. Aberration! in! the! uterine! growth! –! Small! for! Gestational!
o During!the!first!10!days!for!term!babies;!2!weeks!for! Age,!or!Large!for!Gestational!Age!
preterm!babies% 2. Feeding!Difficulties!
o 5<10%!is!considered!normal% o Babies!may!still!vomit!due!to!amniotic!fluid!
o Causes! o Babies! with! so! much! saliva! (mother! with! hx! of!
• Due! to! contraction! of! extracellular! fluid! within! polyhydramnios)!
72!hours% 3. Respiratory!distress!or!apnea!!
• Passage!of!meconium% o Seen!in!pre<term!infants!due!to!lack!of!surfactant!
• Urination!within!24!hours% !
• Removal!of!the!vernix!casseosa% 4. !Cyanosis!
2. Physiologic%Jaundice% o May! be! due! to! cardiac,! pulmonary,! or! metabolic!
o Due!to!the!increase!in!hemolysis!of!fetal!RBCs!which! problems!
has!a!life!of!90!days!(Adult!RBC!–!120!days)% 5. Vomiting/diarrhea/Abdominal!Distension!
o Due! to! the! immaturity! of! the! liver! to! conjugate! and! o May!be!seen!in!infection!
excrete!bilirubin% o Differentiation! of! abdominal! distention! due! to!
o Appears! 2! to! 4! days! of! life! and! disappears! by! 1<2! infection! from! globular! abdomen! must! be! done!
th th
weeks!(7 <10 !day)% through! percussion,! observing! the! veins! seen! and!
3. Physiologic%Anemia% glistening!!
o Due!to!the!rapid!turnover!of!fetal!red!blood!cells! 6. Jaundice!
o Decreased! capacity! of! the! kidneys! to! secrete! o Due!to!liver!immaturity!
erythropoietin! o Usually!resolved!by!exposing!the!baby!to!sunlight!
o Appears!during!the!first!4!months!of!life! o Breastfeeding! jaundice:! Decreased! caloric! intake! in!
4. Inanition%Fever% breast!milk!
o Breast! milk! jaundice:! Substance! in! milk<fatty! acid<
o Dehydration!fever!of!the!newborn!due!to!contraction!
compete!with!albumin!binding!site!
of!extracellular!fluid!and!urination!of!the!baby! 7. Abnormal!Secretions!/!discharges!
rd
o Usually!happens!at!the!3 !day! o Yellow:! from! upper! gastrointestinal! tract! due! to!
5. Witch’s%Milk% atresia!
o Milk! from! baby’s! breast! and! gynecomastia! in! BOTH! o White:!from!pyloric!stenosis!
male!and!female!
8. Bleeding!
o Due! to! maternal! hormonal! withdrawal! particularly!
progesterone! o Especially! in! pre<term! infants! due! to! the! lack! of!
6. Pseudomenses% clotting! factors! particularly! Vitamin! K! dependent!
o Discharge! coming! out! from! the! vagina! often! blood! clotting!factors!
tinged! due! to! maternal! hormonal! withdrawal! 9. Pallor!
particularly!estrogen% o Usually!accompanies!anemia!
o Usually!happens!within!the!first!week% 10. Jitteriness!/!seizures!
7. Falling%Off%Of%The%Umbilical%Cord% o Jitteriness!will!stop!when!baby!is!held,!seizure!won’t!!
o 10! to! 14! days! for! term;! 2! weeks! to! a! month! for! o Probably!because!of!lack!of!myelination!
preterm!due!to!decreased!immune!response!! 11. Meconium!Staining!
8. Passage%Of%Meconium% 12. Temperature!instability!
o One!of!the!causes!of!the!infant’s!weight!loss% !
o Usually!happens!on!the!first!day% %
9. Transitional%Stools% %
o Color! transition! of! stools! from! black! to! greenish! to! %
yellow% %
10. Skin%Desquamation% %
o Due!to!change!in!the!environment!from!being!bathed! %
with!amniotic!fluid!to!being!dry% %
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TPMD%2017|PEDIATRICS%1%–%Physiologic%Changes%in%the%Newborn%and%High%Risk%Infants%|! P a g e !1!!
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!
HIGH%RISK%INFANTS%% !
o Infants! who! should! be! under! close! observation! by! F.%Neonate%
experienced!physicians!and!nurses! o Birthweight!<2500!or!>!4000!grams!
o 9%!of!all!births!require!special!or!neonatal!intensive!care! o Birth!before!37!or!after!42!weeks!of!gestation!
! o Small! for! gestational! age,! Large! for! gestational! age!
A.%Demographic%Social%factors% growth!status!
o Maternal!age!<16!or!>40!years!! o Tachypnea,!cyanosis!
o Illicit!drug,!alcohol,!cigarette!use! o Congenital!malformation!
o Poverty! o Pallor,! plethora,! petechiae! (Usually! have!
o Unmarried! cytomegalovirus!infection)!!
o Emotional!or!physical!stress! !
! MULTIPLE%PREGNANCIES%%
B.%Past%medical%History% (incidence:!Black!&!East!Indians!>!Whites!>!Asians)!
o Genetic!disorders! o Identical! twins! (mononuclear! twin):! 1! ova! fertilized! by! 1!
o Diabetes!Mellitus! sperm!
o Hypertension! o Fraternal!twins!(Polyovular/!dizygotic):!2!eggs!&!e!sperm!
o Asymptomatic!bacteriuria! o >!2!(Triplets,!etc.),!quad,!quin,!setuplets!
o Rheumatologic!illness!(SLE):!congenital!heart!block! o Conjoined!twins!(Siamese!twins,!1:50,000)!
o Long<term!medication! • Late!monoovular!separation!
! • 2!separate!embryo!in!one!amniotic!sac!
C.%Previous%pregnancy% < Thoracoomphalagus! (25%):! Thorax! &! abdomen!
o Intrauterine!fetal!demise! fused!
o Neonatal!death! < Thoracoopagus!(18%):!Fused!thorax!
o Prematurity! < Omphalagus!(10%):!Abdomen!
o Intrauterine!growth!retardation! < Craniopagus!(6%):!Head!
o Congenital!malformations! < Incomplete!duplication!(10%)!
o Incompetent!cervix! o Superfecundation:! 2! ova! fertilized<! different! age! of!
o Blood!group!sensitization,!neonatal!jaundice! gestation!
o Neonatal!thrombocytopenia! o Superfetation:! Another! ovum! is! fertilized! when! there’s!
o Hydrops!fetalis! already! a! fetus! in! the! uterus! (Different! age! of! gestation:!
o Inborn!errors!of!metabolism! when!born!1!is!preterm,!the!other!could!be!term!
! !
D.%Present%pregnancy% Prenatal%diagnosis%of%multiple%pregnancies%
o Vaginal! bleeding! (abruption! placenta,! placenta! o Uterine!size!>!age!of!gestation!
previa)! o Auscultation!of!2!fetal!heart!tones!
o STD! (colonization,! herpes! simplex,! group! B! o Increased!levels!of!maternal!serum!of!α!fetoprotein!&!HCG!
streptococci,!Chlamydia,!syphilis,!Hepatitis!B,!HIV)! o Ultrasound!
o Multiple!gestation! !
o Preeclampsia!(High!blood!pressure!in!mother)! !
o Premature!rupture!of!membranes! Twin%on%
o Short!interpregnancy!time! Arterial%side%(Donor)% Venous%side%(Recipient)%
o Poly<olihohydramnios! Prematurity! Prematurity!
o Acute!medical!or!surgical!illness! Oligohydramnios! Polyhydramnios!
o Inadequate!prenatal!care!(minimum!of!4!visits!to!OB! Small!premature! Hydrops,!large!premature!
prior!to!delivery)! Malnourished! Well<nourished!
o Familial!or!acquired!hypercoagulable!states!
Pale! !
o Treatment!of!infertility!(result!into!multiple!gestation)!
Anemic! Plethoric,!Polycythemia!
!
Hypovolemia! Hypovolemia!
E.%Labor%&%delivery%
Microcardia! Cardiac!hypertrophy!
o Premature!labor!(<37!weeks)!
Myocardial!dysfunction!
o Post!dates!(>42!weeks)!
Tricuspid!valve!regurgitation!
o Fetal!distress!
Right! ventricle! outflow!
o Immature! Lecithin:sphingomyelin! ratio,! absent!
obstruction!
phosphatidylglycerol! (determines! whether! lungs! of!
Glomeruli!small/!normal! Glomeruli!large!
the! baby! are! mature! enough! for! external!
Arterioles!thin<walled! Arterioles!thick!walled!
environment)!
Edematous! due! to! !
o Breech!presentation!
congestion!of!the!heart!
o Meconium!stained!amniotic!fluid!
!
o Nuchal!cord!
%
o Cesarean!section!
% TP
o Forceps!delivery!
%
o APGAR!scores!<!4!at!1!minute!
TPMD%2017|PEDIATRICS%1%–%Physiologic%Changes%in%the%Newborn%and%High%Risk%Infants%|! P a g e !2!!
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Intrauterine%Growth%Retardation% Factors%often%associated%with%Intrauterine%Growth%Retardation!
o A! deviation! from! or! a! reduction! in! an! expected! fetal! o Fetal!
growth!pattern!&!is!caused!by!multiple!adverse!effects!on! • Chromosomal!disorders!
the!fetus! • Chronic!fetal!infections!
! • Congenital!anomalies!
Small%for%Gestational%Age% • Irradiation!
o Weight! is! lower! than! population! norms! or! lower! than! a! • Multiple!gestation!
pre<determined!cut<off! • Pancreatic!hypoplasia!
th th
o Weight!(<250,!5 !percentile,!10 !percentile)! • Insulin!deficiency!
o Maybe!pathologic!or!non<pathologic! • Insulin<like!growth!factor!type!1!deficiency!
o Should!be!delivered!in!a!tertiary!hospital! o Placental!
! • Decreased!placental!weight!or!cellularity!or!both!
Infant%classification%by%gestational%age%
• Decrease!in!surface!area!
o Pre!term:!<!37!weeks!age!of!gestation!
• Villous!placentitis!(bacterial,!viral,!parasitic)!
o Term:!37<42!weeks!age!of!gestation!
• Infarction!
o Post!Term:!<!42!weeks!age!of!gestation!
• Tumor!(chorioangloma,!hydatidiform!mole)!
!
• Placental!separation!
Infant%Classification%by%Weight%at%Birth%
• Twin!transfusion!syndrome!
o Normal!birth!weight:!2500<3999!grams!
o Maternal!
o Very!low!birth!weight:!<1500!grams!
• Toxemia!
o Low!birth!weight:!<!2500!grams!
o Extremely!low!birth!weight:!<1000!grams! • Hypertension!or!renal!disease,!or!both!
! • Hypoxemia! (high! altitude,! cyanotic! cardiac! or!
Asymmetric/%Symmetric%Intrauterine%Growth%Retardation%% pulmonary!disease)!
o Based!on!head!circumference,!weight,!and!length! • Malnutrition!or!chronic!illness!
o Asymmetric:!! • Sickle!cell!anemia!
• Length,!head!circumference!normal! • Drugs! (narcotics,! alcohol,! cigarettes,! cocaine,!
•
th
Weight!is!less!than!10 !percentile! antimetabolites)!
• Late!onset! !
!
• Usually! due! to! acute! maternal! nutrition,! late! onset!
infection,!cardiac!anomalies!
o Symmetric:!!
th
• Weight,! length,! head! circumference! less! than! 10 !
percentile!
• Early!onset!
• Usually! due! to! infection,! chronic! maternal! illness,!
congenital!anomalies!
%
%
Evaluation% &% Management% for% Complications% of% Intrauterine%
Growth%Retardation/%Small%for%Gestational%Age%
o Hypoxia,!acidosis:!Congenital!anomalies!
o Infection:!Perinatal!discharge!
o Meconium!aspiration!
o Pulmonary!hemorrhage!
o PPHN!
o Hypothermia!
o Hypoglycemia!
o Hypocalcemia!
o Hyponatremia!
o Polycythemia!
!
!
!
!
!
!
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!
TP
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TPMD%2017|PEDIATRICS%1%–%Physiologic%Changes%in%the%Newborn%and%High%Risk%Infants%|! P a g e !3!!
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 ESSENTIALS%IN%NEWBORN%CARE%
%
PROVIDING%WARMTH:%CHECK%THE%ENVIRONMENT% • Position! prone! on! the! mother’s! abdomen! or!
o Check! the! temperature! of! the! delivery! room! (Ideal! chest!
temperature!is!25<28!C)% • Cover! the! newborn! with! dry! linen! for! the! back!
o Check!for!air!drafts% and!bonnet!for!the!head!
o Turn!air!conditioner!off!before!the!delivery% !
% 3. PROPERLYSTIMED%CORD%CLAMPING%
NEWBORN%CARE%PRACTICES% o Benefits!of!Properly<timed!Cord!Clamping:!
1. IMMEDIATE%AND%THOROUGH%DRYING% • Term!–!less!anemia!
o Immediate%Drying% • Pre<term! –! less! anemia! and! less! incidence! of!
• Stimulates!breathing% intravascular!hemorrhage!!
• Prevents!hypothermia% o When! preparing! for! delivery,! have! 2! pairs! of! gloves!
o Hypothermia%can%lead%to:% after!thorough!handwashing!
• Infection! o Remove!the!first!set!of!gloves!
• Coagulation!defects! o Palpate!the!umbilical!cord!
• Acidosis! o Wait! 1<3! minutes! or! until! cord! pulsations! have!
• Delayed!fetal!to!newborn!circulatory!adjustment! stopped!
• Hyaline!membrane!disease! o Procedure!
• Brain!hemorrhage! • Clamp!cord!using!a!sterile!plastic!clamp!or!tie!at!
o Dry! thoroughly! for! a! FULL! 30! SECONDS! unless! the! 2!cm!from!the!umbilical!base!
infant!is!both!floppy/limp!or!apneic% • Clamp!again!at!5!cm!from!the!base!
• Do!a!quick!check!of!breathing!while!drying% • Cut!the!cord!close!to!the!plastic!clamp!
• More! than! 95%! of! newborns! breath! normally! o Do!not!milk!the!cord!toward!the!baby!
after!birth% o Observe!for!the!oozing!of!blood.!If!blood!oozes,!place!
o Wipe!gently,!do!not!wipe!off!the!vernix!casseosa% a!second!tie!between!the!skin!and!the!clamp!
o Remove!the!wet!cloth,!replace!with!a!dry!one% o DRY!CORD!CARE!is!recommended!–!Do!not!apply!any!
o If!baby!is!not!breathing,!STIMULATE!BY!DRYING% substance!onto!the!cord!
o Do!not!slap,!shake!or!rub!thebaby% o Do!not!use!a!binder!or!“bigkis”!
o Do! not! ventilate! unless! the! baby! is! floppy/limp! and! !
not!breathing% Harm%of%Early%Bathing%
o Do%not%suction%unless%the%mouth%or%nose%is%blocked% o Removes! vernix! casseosa,! which! is! a! protective!
by%secretion% barrier!to!E.)coli)and!Group)B)Streptococci!
• Suctioning!has!no!proven!benefit! o Hinders!crawling!reflex!
• No! benefit! of! routine! suction! for! babies! born! o Can!lead!to!hypothermia!
with!meconium!stained!amniotic!fluid! %
• Oropharyngeal! suctioning! is! not! indicated! for! a! 4. NONSSEPARATION% OF% NEWBORN% FROM% MOTHER% FOR%
healthy,!vigorous!baby! EARLY%BREASTFEEDING%
• Adverse!effects!if!inexpertly!performed:! o Weighing,!bathing,!eye!care,!examinations,!injections!
→ Apnea! should! be! done! after! the! first! full! breastfeed! is!
→ Vagal<induced!bradycardia! completed!
o Postpone!bathing!until!at!least!6!hours!
→ Slower!rise!in!oxygen!saturations!
o Never!leave!the!mother!and!baby!unattended!
→ Mucosal!trauma!with!possibly!an!increased!
o Monitor! mother! and! baby! every! 15! minutes! in! the!
risk!for!infection!
first!1<2!hours.!Assess!breathing!and!warmth.!
• Suctioning) should) be) done) only) if) chest) is) not)
• Breathing:! listen! for! grunting,! look! for! chest! in<
rising) with) bag) and) mask) ventilation) and) there)
drawing!and!fast!breathing!
are) visible) secretions) in) the) mouth) and/or) nose)
• Warmth:!check!to!see!if!feet!are!cold!to!touch!if!
that)appear)to)be)obstructing)the)upper)airway)
there!is!no!thermometer!
)
o Leave! the! newborn! between! the! mother’s! breast! in!
2. EARLY%SKINSTOSSKIN%CONTACT%
continuous!skin<to<skin!contact!
o General! perception! is! purely! for! mother<baby!
o The! baby! may! want! to! rest! for! 20<30! minutes! and!
bonding!
even! up! to! 120! minutes! before! showing! signs! of!
o Other!benefits:!
readiness!to!feed!
• Breastfeeding!success!
o Breastfeeding%Cues%
• Lymphoid!tissue!system!stimulation!
• Eye!movement!under!closed!lids!
• Exposure!to!maternal!skin!flora!
• Increased! alertness,! movements! of!
• Sugar!(protection!from!hypoglycemia)!
arms!and!legs!
• Thermoregulation!
• Tossing,! turning! or!
o If!breathing!or!crying:!
wiggling! TP

TPMD%2017|PEDIATRICS%1%–%Essentials%in%Newborn%Care%|! P a g e !1!!
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 • Mouthing,!licking,!tonguing!movements!
• Rooting!
• Changes!in!facial!expression!
• Squeaking!noises!or!light!fussing!
• Crying)is)a)LATE)sign)of)hunger)
)
o Health!workers!should!not!touch!the!newborn!unless!
there!is!a!medical!indication!
o Do!not!give!sugar!water,!formula!or!other!prelacteals!
o Do!not!give!bottles!or!pacifiers!
o Do!not!throw!away!colostrum!
o Let!the!baby!feed!for!as!long!as!he/she!wants!on!both!
breasts!
o Help!the!mother!and!baby!into!a!comfortable!position!
o Once! the! newborn! shows! feeding! cues,! ask! the!
mother! to! encourage! her! newborn! to! move! toward!
the!breast!
o After!delivery,!mother!is!moved!onto!a!stretcher!with!
her! baby! and! transported! to! the! recovery! room,! or!
private!room!
o Breastfeeding!support!is!continued!
o Counsel!on!positioning!
• Newborn’s!neck!is!not!flexed!or!twisted!
• Newborn!is!facing!the!breast!
• Newborn!is!close!to!mother’s!body!
• Newborn’s!whole!body!is!supported!
o Counsel!on!attachment!and!suckling!
• Mouth!wide!open!
• Lower!lip!turned!outwards!
• Baby’s!chin!touching!breast!
• Sucking!is!slow,!deep!with!some!pauses!
%
%
)
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)!

TP

TPMD%2017|PEDIATRICS%1%–%Essentials%in%Newborn%Care%|! P a g e !2!!
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 MATURITY%TESTING%IN%THE%NEWBORN%
%
IMPORTANCE%OF%MATURITY%TESTING%% gasping!
o !Decision-making!regarding!acute!or!chronic!nursery!care! Muscle% Flaccid! Some!flexion! Well-flexed,!
o !Later!post-discharge!follow-up! tone% of!arms!and! or!active!
o !Population!research!statistics! legs! movements!
!! of!
WAYS%TO%DETERMINE%AGE%OF%GESTATION% extremities!
o Last!Menstrual!Period! Reflex%or% No! Grimace!or! Good!cry!
o Fundic!Height! irritability% response! weak!cry!
o Abdominal!ultrasound! Color% Blue!all! Body!pink,! Pink!all!over!
o Quickening! over,!or! hands!and!feet!
pale! blue!
o Expanded!Ballard!Score!
o Fundoscopic!examination!by!direct!ophthalmoscopy!!!! %
!! Reflex%Catheter%in%Nostril%
CLASSIFICATION%OF%THE%NEWBORN%INFANT% o 0%–%No%response%
By%Age%of%Gestation% o 1%–%Grimace%
o !Preterm!infant!–!completed!<!37!weeks!age!of!gestation! o 2%–%Cough%or%sneeze%
o !Term! infants! –! delivered! between! 37-42! weeks! age! of! %
gestation!! APGAR%SCORE%INTERPRETATION%
o !Post!term!infants!–!>!42!weeks!age!of!gestation! o 7!or!greater!–!Normal!
% o 4–6!–!Borderline!
By%Birth%Weight% o 3!or!less!–!Severely!Depressed!
o !Low!birth!weight!(LBW)!–!less!than!2,500!grams!at!birth! !
o !Very!low!birth!weight!(VLBW)!–!less!than!1,500!at!birth! Asphyxia%as%related%to%APGAR%Score%
o !Extremely! low! birth! weight! ! (ELBW)! –! less! than! 1,000! o Mild!asphyxia!–!5-7%
grams!at!birth! o Moderate!asphyxia!–!3-4%
! o Severe!asphyxia!–!0-2%
LUBCHENCO%CHART%/%COLORADO%CHART% %
o Classification! of! Newborns! based! on! maturity! and! How%to%Evaluate%Infant%through%APGAR%Score%
intrauterine!growth! 1. Appearance%
o Parameters! included! are! length,! head! circumference,! o Observe!the!peripheral!skin,!oral!mucosa!and!tongue%
weight,!and!intrauterine!weight-length!ratio! 2. Pulse%
! o Single!most!important!feature!of!the!scoring!system%
APGAR%SCORE% o Listen! to! the! apical! heart! rate! or! palpate! the!
o Introduced!by!Virginia!Apgar,!in!1952! pulsations!of!the!umbilical!cord%
o Designed! to! quickly! evaluate! a! newborn's! physical! o Count!for!6!seconds!and!multiply!by!10%
condition!and!to!see!if!there's!an!immediate!need!for!extra! 3. Grimace%
medical!or!emergency!care! o Observe!reaction!to!suctioning,!stimulation!of!sole!of!
o It! was! not! designed! to! predict! a! baby's! long-term! health,! foot,!etc.%
behavior,!intellectual!status,!personality,!or!outcome! 4. Activity%
o Usually!given!to!a!baby!twice:!once%at%1%minute%after%birth,% o Observe!flexion!of!elbows!and!hips%
and%again%at%5%minutes%after%birth.! 5. Respiration%
o If! there! are! concerns! about! the! baby's! condition,! the! test! o Observe!the!infant’s!chest!as!it!rises!and!fall%
may!be!scored!for!a!third!time!at!10!minutes!after!birth.! o RR!>!60!bpm;!if!<!40!bpm,!abnormal%
o Five!factors!are!used!to!evaluate!the!baby's!condition!and! %
each!factor!is!scored!on!a!scale!of!0!to!2,!with!2!being!the! %
best!score:! Factors%Affecting%the%APGAR%Score%
1. Appearance!(skin!color)! A. False%Positive%
2. Pulse!(heart!rate)! o Immaturity%
3. Grimace!response!(reflexes)! o Analgesics,!sedatives,!narcotics%
4. Activity!(muscle!tone)! o Magnesium!sulfate%
5. Respiration!(breathing!rate!and!effort)! o Acute!cerebral!trauma%
o 10! is! the! highest! score! possible,! but! it's! rarely! obtained! o Precipitous!delivery%
since! normal! newborns! usually! have! acrocyanosis% due% to% o Congenital!myopathy%
vasomotor%instabilities% o Spinal!cord!trauma%
Sign% SCORE%0% SCORE%1% SCORE%2% o CNS!anomaly%
o Lung!abnormality%
Heart%rate% Absent! Below!100!per! Above!100!
minute! per!minute! o Airway!obstruction%
o Congenital!pneumonia%
Respiratory% Absent! Weak,! Good,!crying!
% TP
effort% irregular,!or!

TPMD%2017|PEDIATRICS%1%–%Maturity%Testing%in%the%Newborn%|! P a g e !1!!
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B. False%Negative%
o Maternal!acidosis%
o High!fetal!catecholamine!level%
o Inborn!errors!of!metabolism!
!
EXPANDED%BALLARD%SCORE%
o An!expansion!and!refinement!of!the!original!Ballard!Score!
o Allows!aging!of!the!neonate!below!26!weeks!
o Accurate!to!+/-!2!weeks!
o It! is! important! to! adhere! to! the! various! neurological!
maneuvers!and!measures!of!physical!maturity!
o Tests!passive!flexor!tone!!
o Infants!should!be!examined!once!stable!
o Extremely%preterm%infants%should%be%scored%within%the%first%
12% hours% of% life% before% the% skin% undergoes% significant%
changes%
o Full! term! infants! are! scored! as! early! as! possible,! but!
reliably!even!up!to!72!hours!old!!!
o Not!to!be!performed!with:!
• Asphyxia!–!no!muscle!tone!
• Breech!delivery!–!take!time!for!legs!to!extend!
• Congenital!anomalies!
• Fractures!or!bone!disorders!
! peeling,! cracking,! dehydration,! and! imparting! a!
Neuromuscular%Testing%
1. Posture%
o Total! body! muscle! tone! is! reflected! in! the! infant's!
preferred!posture!at!rest!and!resistance!to!stretch!of!
individual!muscle!groups.!!
o As! maturation! progresses,! the! fetus! gradually!
assumes!increasing!passive!flexor!tone!that!proceeds!
in! a! centripetal! direction,! with! lower! extremities!
slightly!ahead!of!upper!extremities.!
2. Square%Window%
o Wrist! flexibility! and/or! resistance! to! extensor!
stretching! are! responsible! for! the! resulting! angle! of!
flexion!at!the!wrist.!
o The! examiner! straightens! the! infant's! fingers! and!
applies! gentle! pressure! on! the! dorsum! of! the! hand,!
close!to!the!fingers.!
3. Arm%Recoil%
o This! maneuver! focuses! on! passive! flexor! tone! of! the!
biceps! muscle! by! measuring! the! angle! of! recoil!
following!very!brief!extension!of!the!upper!extremity.!
4. Popliteal%Angle%
o This! maneuver! assesses! maturation! of! passive! flexor!
tone!about!the!knee!joint!by!testing!for!resistance!to!
extension!of!the!lower!extremity.!!
o With! the! infant! lying! supine,! and! with! diaper! re-
moved,! the! thigh! is! placed! gently! on! the! infant's!
abdomen!with!the!knee!fully!flexed.!
o The!prenatal!frank!breech!position!will!interfere!with!
this!maneuver!for!the!first!24!to!48!hours!of!age!due!
to!prolonged!intrauterine!flexor!fatigue.!
5. Scarf%Sign%
o This! maneuver! tests! the! passive! tone! of! the! flexors!
about!the!shoulder!girdle.!
o Landmarks!noted!in!order!of!increasing!maturity!are:!
full! scarf! at! the! level! of! the! neck! (-1);! contralateral!
axillary! line! (0);! contralateral! nipple! line! (1);! xyphoid!
TPMD%2017|PEDIATRICS%1%–%Maturity%Testing%in%the%Newborn%|! P a g e !2!!
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process! (2);! ipsilateral! nipple! line! (3);! and! ipsilateral!
axillary!line!(4).!
6. Heel%to%Ear%
o This! maneuver! measures! passive! flexor! tone! about!
the! pelvic! girdle! by! testing! for! passive! flexion! or!
resistance! to! extension! of! posterior! hip! flexor!
muscles.!
o Landmarks! noted! in! order! of! increasing! maturity!
include!resistance!felt!when!the!heel!is!at!or!near!the:!
ear! (-1);! nose! (0);! chin! level! (1);! nipple! line! (2);!
umbilical!area!(3);!and!femoral!crease!(4).!
%
Physical%Maturity%Testing%
1. Skin%
o Maturation!of!fetal!skin!involves!the!development!of!
its! intrinsic! structures! concurrent! with! the! gradual!
loss!of!its!protective!coating,!the!vernix!caseosa.!!
o Hence,! it! thickens,! dries! and! becomes! wrinkled!
and/or! peels,! and! may! develop! a! rash! as! fetal!
maturation!progresses.!
o At! term! and! post-term,! the! fetus! may! expel!
meconium! into! the! amniotic! fluid.! This! may! add! an!
accelerating! effect! to! the! drying! process,! causing!
parchment,!then!leathery,!appearance!to!the!skin.!
2. Lanugo%
o In! extreme! immaturity,! the! skin! lacks! any! lanugo.! It!
begins! to! appear! at! approximately! the! 24th! to! 25th!
week! and! is! usually! abundant,! especially! across! the!
shoulders! and! upper! back,! by! the! 28th! week! of!
gestation.!
o Thinning! occurs! first! over! the! lower! back,! wearing!
away!as!the!fetal!body!curves!forward!into!its!mature,!
flexed!position.!Bald!areas!appear!and!become!larger!
over!the!lumbo-sacral!area.!At!term,!most!of!the!fetal!
back!is!devoid!of!lanugo,!i.e.,!the!back!is!mostly!bald.!
!
3. Plantar%Surface%
o This! item! pertains! to! the! major! foot! creases! on! the!
sole! of! the! foot.! The! first! appearance! of! a! crease!
appears! on! the! anterior! sole! at! the! ball! of! the! foot.!
this! may! be! related! to! foot! flexion! in! utero,! but! is!
contributed!to!by!dehydration!of!the!skin.! !
4. Breast%
o The! breast! bud! consists! of! breast! tissue! that! is!
stimulated! to! grow! by! maternal! estrogens! and! fatty!
tissue! which! is! dependent! upon! fetal! nutritional!
status.!
5. Eye/Ear%
o The! pinna! of! the! fetal! ear! changes! it! configuration!
and! increases! in! cartilage! content! as! maturation!
progresses.!!
o Assessment!includes!palpation!for!cartilage!thickness,!
then! folding! the! pinna! forward! toward! the! face! and!
releasing!it.!!
o The! examiner! notes! the! rapidity! with! which! the!
folded! pinna! snaps! back! away! from! the! face! when!
released,! then! selects! the! square! that! most! closely!
describes! the! degree! of! cartilagenous!
development.!
o In!very!premature!infants,!the!
pinnae! may! remain! folded! TP
when! released.! In! such!
 infants,! the! examiner! notes! the! state! of! eyelid! !
development! as! an! additional! indicator! of! fetal! !
maturation.! !
! !
6. Genitals% !
Males% !
o Testicles! found! inside! the! rugated! zone! are! !
st barely considered!
flat areola descended.!
stippled In! extreme!
raised prematurity!
full areola the!
5 NA !
perceptible no bud is!areola
scrotum! flat,! 1smooth!
mm areola and!3 mm mmsexually!
appears! bud !
bud bud
undifferentiated.! At! term! to! post-term,! the! scrotum! !
pinna flat may! become!well-curved
slightly pendulous! and! may! actually!
formed & touch!
thick the! NA !
stays folded mattress!when!the!infant!lies!supine.!
curved pinna soft firm with cartilage ear !
pinna soft with ready instant stiff
with slow recoil recoil !
Females%
recoil !
o In! extreme! prematurity,! the! labia! are! flat! and! the!
als scrotum NA testes testes down testes NA !
clitoris!is!very!prominent!and!may!resemble!the!male!
empty no descend-ing good rugae pendulous !
rugae phallus.! As! fewmaturation!
rugae progresses,! deep
the! rugae
clitoris!
!
becomes! less! prominent! and! labia! minora! become!
!
more!prominent.!Nearing!term,!both!clitoris!and!labia!
als prominent NA majora & majora large majora NA !
le clitoris & minora! recede!minora
and! are! eventually!
minoraenveloped! by! the!
cover clitoris !
labia minora enlarging!labia!majora.!
equally small & minora
prominent !
o The! labia! majora! contain! fat! and! their! size! are!
!
affected!by!intrauterine!nutrition.!Over-nutrition!may!
!
result! in! large! labia! majora! earlier! in! gestation,!
!
whereas! under-nutrition,! as! in! intrauterine! growth!
rd Score = !
retardation!or!post-maturity,!may!result!in!small!labia!
!
majora! with! relatively! prominent! clitoris! and! labia!
M (points for each parametet) !
minora! late! into! gestation.! These! findings! should! be!
!
pretation: reported!as!observed,!since!a!lower!score!on!this!item!
!
in! the! chronically! stressed! or! growth! retarded! fetus!
imum score: 0 !
may!be!counter-balanced!by!a!higher!score!on!certain!
!
ximum score: 54 neuro-muscular!items.!
!
!
!
! Correlation of score with gestational age
!
!
!
! Score Week
!
! 5 26
!
! 10 28 ! !
!
15 30
!
20 32
25 34
30 36
35 38
40 40
45 42
50 44

rences:

rd JL Novak KK Driver M. A simplified score for assessment of fetal maturation of newly born
ts. J Pediatr. 1979; 95: 769-774.

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TPMD%2017|PEDIATRICS%1%–%Maturity%Testing%in%the%Newborn%|! P a g e !5!!
!
!
 DEVELOPMENTAL%SCREENING%TOOLS%
%
DEVELOPMENTAL%SCREENING% MODIFIED%CHECKLIST%FOR%AUTISM%IN%TODDLERS%(MQCHAT)%
o Administration! of! brief,! formal,! standardized! evaluation! o Screen! for! Autism! Spectrum! Disorder! (ASD)! in! toddlers!
that!aids!in!the!early!identification!of!patients!at!risk!for!a! (16J30!months)%
developmental!and/or!behavioral!disorder! o Tests!for!ASD!against!normally!developing!children%
! o A!parent!can!complete!the!items!independently%
WHY%DO%DEVELOPMENTAL%SCREENING?% o Has!excellent!sensitivity!and!specificity%
o Developmental!and!social,!emotional!delays!can!be!subtle! o Positive! results! suggest! a! high! risk! for! an! ASD,! and! may!
and! can! occur! in! children! who! appear! to! be! developing! necessitate!referral%
typically! o There!are!23%items%in%MQCHAT%%
o Most! children! would! benefit! from! early! intervention! are! o Critical!Items%
not!identified!until!after!they!start!school! • 2!–!Does!your!child!take!an!interest!in!other!children?%
o Even!pediatricians!and!child!health!specialist!fail!to!detect! • 7!–!Does!your!child!ever!use!his!index!finger!to!point,!
delays! more! than! 70%! of! the! time! when! they! rely! on! to!indicate!interest!in!something?%
clinical!judgment!alone! • 9!–!Does!your!child!ever!bring!objects!to!you!to!show!
o Screening! results! will! enable! child! health! specialists! to! you!something?%
initiate!early!intervention! • 13!–!Does!your!child!imitate!you?%
! • 14! –! Does! your! child! respond! to! his/her! name! when!
EARLY%INTERVENTION% you!call?%
o Proved! special! services! and! programs! for! children! from! • 15! –! I! f! you! paint! a! toy! across! the! room,! does! your!
birth!to!age!3!who!have:! child!look!at!it?%
• Developmental!delays! o A%child%fails%the%checklist:%
• A! physical! or! mental! condition! know! to! cause! • When%2%or%more%critical%items%are%failed;%or%
developmental!delays! • When%any%three%items%are%failed%
o Critical!to!the!success!of!children!with!disabilities! o Not!all!children!who!fail!the!checklist!will!meet!the!criteria!
o Prepare! children! for! the! future! academic! tasks! they! will! for!the!diagnosis!on!the!autism!spectrum%
need! to! master! as! part! of! the! general! education! o However,!children!who!failed!should!be!evaluated!in!more!
curriculum! depth! by! the! physician! or! referred! for! a! developmental!
o An!early!intervention!program!should!significantly!increase! evaluation!with!a!specialist%
their! functional! skills! and! their! successful! entry! into! the! %
adulthood! DENVER%II%
! o Test! for! screening! cognitive! and! behavioral! problems! in!
IDEAL%SCREENING%METHOD% school!children%
o Should!be!easy!to!perform!and!interpret! o Enables! the! clinician! to! identify! children! whose!
o Should!be!inexpensive! development! deviates! significantly! from! that! of! other!
o Should!have!a!good!sensitivity!and!specificity! children! warranting! further! investigation! to! determine! if!
o Should! have! sensitivity! and! specificity! at! 70J80%! range! there!exists!a!problem!requiring!treatment%
(American!Academy!of!Pediatrics)! %
! PARENT’S%EVALUATION%OF%DEVELOPMENTAL%STATUS%(PEDS)%
DEVELOPMENTAL%SCREENING%TOOLS% o 10Jquestion! parental! questionnaire! developed! by! Frances!
o Do!not!provide!diagnosis! Glascoe!that!can!be!completed!in!5!minutes,!only!requiring!
o When! a! child! passes/fails! a! screening! test,! he! should! be! th th
the!literacy!of!a!4 !or!5 !grade%
given! the! opportunity! to! have! developmentally! o Tests!for!age!birth!up!to!8!years!old%
appropriate!activities! o Test!sensitivity:!74J80%!
o When! a! child! fails! a! screening! test,! a! close! follow! up! is! o Test!specificity:!70J80%!
needed!and!he!may!need!to!have!further!assessment! o PEDS%QUESTIONS%
! 1. Please! list! any! concerns! about! your! child’s! learning,!
AGES%AND%STAGES%QUESTIONNAIRE% development!and!behavior?!
o Series% of% 20% questionnaire! that! correspond! to! age! Do%you%have%any%concerns%about%how%your%child:%
intervals!from!birth!to!6!years!! 2. …talks! or! makes! speech! sounds?! (expressive!
o Each! questionnaire! contains! questions! for! parents! to! language)!
answer!about!activities!their!child!is!(or!is!not)!able!to!do! 3. …understands!what!you!say?!(receptive!language)!
o Answers! are! scored! and! help! to! determine! whether! the! 4. …uses!his!hands!and!finger!to!do!things?!(fine!motor)!
development! is! on! schedule! or! whether! the! child! should! 5. …uses!his!arms!and!legs?!(gross!motor)!
be! referred! for! a! developmental! checkup! with! a! 6. …behaves?!(behavior)!
professional! 7. …gets!along!well!with!others?!(socialJemotional)!
o Activities! discussed! in! each! questionnaire! reflect! 8. …is!learning!to!do!things!for!himself?!(selfJhelp)!
developmental!milestones!for!each!age!group! 9. …is! learning! preJschool! or! school! skills!
! (school)!
! 10. Please! list! any! other!
TP
! concerns!

TPMD%2017|PEDIATRICS%1%–%Developmental%Screening%Tools%|! P a g e !1!!
o Certain! developmental! concerns! at! different! ages! are!
predictive!of!a!developmental!disability!
o If%two%or%more%predictive%concerns%are%found:%
• The!patient!should!be!referred!for!either!speech!and!
language! assessment,! audiology! testing,! or! for!
intellectual!and!education!evaluation%
o If%one%predictive%concern%is%found:%
• Patient! should! come! back! for! either! secondJstage!
developmental! screening! or! for! other! more! specific!
concerns%
o If%a%nonQpredictive%concern%is%found:%
• Additional! screening,! behavioral! counseling,! or!
referral!to!a!community!program!may!be!appropriate%
o If%the%parent%does%not%write%down%any%concerns:%
• Be!sure!to!consider!whether!the!parent!has!literacy!or!
language!barriers!before!assuming!the!parent!has!no!
concerns%
%
%

%
%
TP
% %

TPMD%2017|PEDIATRICS%1%–%Developmental%Screening%Tools%|! P a g e !2!!
MQCHAT%% MQCHATQR/F% (Modified% Checklist% for% Autism% in% Toddlers,%
Please! fill! out! the! following! about! how! your! child! usually! is.! Revised%with%FollowQUp)%
Please!try!to!answer!every!question.!If!the!behavior!is!rare!(e.g.,! 1. If! you! point! at! something! across! the! room,! does! your!
you've!seen!it!once!or!twice),!please!answer!as!if!the!child!does! child!look!at!it?!(FOR!EXAMPLE,!if!you!point!at!a!toy!or!an!
not!do!it.!! animal,!does!your!child!look!at!the!toy!or!animal?)!
! 2. Have!you!ever!wondered!if!your!child!might!be!deaf?!
1. Does! your! child! enjoy! being! swung,! bounced! on! your! 3. Does! your! child! play! pretend! or! makeJbelieve?! (FOR!
knee,!etc.?!! EXAMPLE,! pretend! to! drink! from! an! empty! cup,! pretend!
2. Does%your%child%take%an%interest%in%other%children?%% to! talk! on! a! phone,! or! pretend! to! feed! a! doll! or! stuffed!
3. Does!your!child!like!climbing!on!things,!such!as!up!stairs?!! animal?)!
4. Does!your!child!enjoy!playing!peekJaJboo/hideJandJseek?!! 4. Does! your! child! like! climbing! on! things?! (FOR! EXAMPLE,!
5. Does!your!child!ever!pretend,!for!example,!to!talk!on!the! furniture,!playground!equipment,!or!stairs)!
phone!or!take!care!of!a!doll!or!pretend!other!things?!! 5. Does!your!child!make!unusual!finger!movements!near!his!
6. Does!your!child!ever!use!his/her!index!finger!to!point,!to! or!her!eyes?!(FOR!EXAMPLE,!does!your!child!wiggle!his!or!
ask!for!something?!! her!fingers!close!to!his!or!her!eyes?)!
7. Does%your%child%ever%use%his/her%index%finger%to%point,%to% 6. Does!your!child!point!with!one!finger!to!ask!for!something!
indicate%interest%in%something?%% or!to!get!help?!(FOR!EXAMPLE,!pointing!to!a!snack!or!toy!
8. Can! your! child! play! properly! with! small! toys! (e.g.! cars! or! that!is!out!of!reach)!
blocks)! without! just! mouthing,! fiddling,! or! dropping! 7. Does! your! child! point! with! one! finger! to! show! you!
them?!! something! interesting?! (FOR! EXAMPLE,! pointing! to! an!
9. Does% your% child% ever% bring% objects% over% to% you% (parent)% airplane! in! the! sky! or! a! big! truck! in! the! road.! This! is!
to%show%you%something?%% different! from! your! child! pointing! to! ASK! for! something!
10. Does! your! child! look! you! in! the! eye! for! more! than! a! [Question!#6.])!
second!or!two?!! 8. Is!your!child!interested!in!other!children?!(FOR!EXAMPLE,!
11. Does! your! child! ever! seem! oversensitive! to! noise?! (e.g.,! does!your!child!watch!other!children,!smile!at!them,!or!go!
plugging!ears)!! to!them?)!
12. Does! your! child! smile! in! response! to! your! face! or! your! 9. Does!your!child!show!you!things!by!bringing!them!to!you!
smile?!! or! holding! them! up! for! you! to! see! J! not! to! get! help,! but!
13. Does%your%child%imitate%you?%(e.g.,%you%make%a%faceQwill% just! to! share?! (FOR! EXAMPLE,! showing! you! a! flower,! a!
your%child%imitate%it?)%% stuffed!animal,!or!a!toy!truck)!
14. Does%your%child%respond%to%his/her%name%when%you%call?%% 10. Does!your!child!respond!when!you!call!his!or!her!name?!
15. If% you% point% at% a% toy% across% the% room,% does% your% child% (FOR!EXAMPLE,!does!he!or!she!look!up,!talk!or!babble,!or!
look%at%it?%% stop! what! he! or! she! is! doing! when! you! call! his! or! her!
16. Does!your!child!walk?!! name?)!
17. Does!your!child!look!at!things!you!are!looking!at?!! 11. When!you!smile!at!your!child,!does!he!or!she!smile!back!
18. Does! your! child! make! unusual! finger! movements! near! at!you?!
his/her!face?!! 12. Does! your! child! get! upset! by! everyday! noises?! (FOR!
19. Does! your! child! try! to! attract! your! attention! to! his/her! EXAMPLE,!does!your!child!scream!or!cry!to!noise!such!as!a!
own!activity?!! vacuum!cleaner!or!loud!music?)!
20. Have!you!ever!wondered!if!your!child!is!deaf?!! 13. Does!your!child!walk?!
21. Does!your!child!understand!what!people!say?!! 14. Does!your!child!look!you!in!the!eye!when!you!are!talking!
22. Does! your! child! sometimes! stare! at! nothing! or! wander! to!him!or!her,!playing!with!him!or!her,!or!dressing!him!or!
with!no!purpose?!! her?!
23. Does! your! child! look! at! your! face! to! check! your! reaction! 15. Does!your!child!try!to!copy!what!you!do?!(FOR!EXAMPLE,!
when!faced!with!something!unfamiliar?!! wave!byeJbye,!clap,!or!make!a!funny!noise!when!you!do)!
! 16. If! you! turn! your! head! to! look! at! something,! does! your!
! child!look!around!to!see!what!you!are!looking!at?!
! 17. Does!your!child!try!to!get!you!to!watch!him!or!her?!(FOR!
! EXAMPLE,! does! your! child! look! at! you! for! praise,! or! say!
! "look"!or!"watch!me"?)!
! 18. Does! your! child! understand! when! you! tell! him! or! her! to!
! do! something?! (FOR! EXAMPLE,! if! you! don't! point,! can!
! your! child! understand! "put! the! book! on! the! chair"! or!
! "bring!me!the!blanket"?)!
! 19. If! something! new! happens,! does! your! child! look! at! your!
! face!to!see!how!you!feel!about!it?!(FOR!EXAMPLE,!if!he!or!
! she!hears!a!strange!or!funny!noise,!or!sees!a!new!toy,!will!
! he!or!she!look!at!your!face?)!
! 20. Does!your!child!like!movement!activities?!(FOR!
! EXAMPLE,! being! swung! or! bounced! on!
! your!knee)!
! TP

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 GROWTH%AND%DEVELOPMENT%%
Newborn%to%Middle%Childhood
% %
GROWTH% Dental%Development%
o Process!by!which!a!living!being!or!any!part!increases!in!size! o Mineralization!begins!as!early!as:!
and! mass! over! time! either! by! multiplication! or! by! • Second!trimester!to!3!years!for!deciduous!teeth!
enlargement!of!component!cells% • Up!to!25!years!for!permanent!teeth!
% o Eruption! begins! with! the! central! incisors! and! progresses!
Measured%in%terms%of:% laterally!
Weight% o Exfoliation! begins! at! 6! years! old! and! continues! up! to! 12!
o More! sensitive! index! of! acute! episodes! of! ill! health! and! years!of!age!
nutritional!status% o Teeth!should!appear!at!13!months!
o At!3>4!months:!20!grams/day% • Delayed! eruption! –! hypothyroidism,!
o At!4!months:!birth!weight!is!doubled% hypoparathyroidism! and! other! disorders! involved! in!
o At!1!year:!birth!weight!is!tripled% bone!metabolism!
% %
Length/Height% WHO%Child%Growth%Standards%
o Best!measure!of!skeletal!growth% o Weight!for!age:!0>24!months!
o Average!length!of!newborn:!50!cm% o Height!(length)!for!age:!2>5!years!
o At!1!year:!length!has!increased!by!50%% o Head!circumference!
% o Weight!for!Height!
Head%circumference% o BMI:!for!children!>2!years!old!
o Tape! measure! placed! over! the! supraorbital! ridge! in! front! %
and! extended! circumferentially! to! include! the! most! DEVELOPMENT%
prominent!part!of!the!occiput% o A! complete! process! of! growing! and! acquiring! skills!
o Measured!until!the!child!is!3!years!old% occurring! in! an! orderly! predictable! pattern! as! a! result! of!
% maturation!and!experience%
Chest%circumference% o Reflects! the! increase! in! skills! and! complexity! of! function!
o Done! at! mid>inspiration! with! xiphoid! notch! as! the! performed!by!an!individual%
reference!point% %
% Principles%of%Development%
Other%parameters%and%predictors%of%growth% o Continuous!process!from!conception!to!maturity%
MidOArm%Circumference% o Depends! on! maturation! and! myelination! of! the! nervous!
o Circumference! of! the! left! upper! arm,! measured! at! mid> system%
point! between! the! tip! of! the! shoulder! and! the! tip! of! the! o Sequence!of!development!is!the!same!for!all!children%
elbow!(olecranon!process!and!acromion)% o Certain! primitive! reflexes! have! to! be! lost! before! the!
% voluntary!movement!develops%
Skinfold%Thickness% o Direction!of!development!is!cephalocaudal%
o Method!for!quantifying!adiposity!by!using!a!triceps!caliper! o Generalized! mass! activity! gives! way! to! specific! individual!
to!measure!the!skin!under!the!scapula% responses!(from!gross!to!fine!motor)%
% %
Body%Proportions% Developmental%Milestones%
o Head!and!trunk!are!relatively!large!at!birth% o A! set! of! functional! skills! or! age>specific! tasks! that! most!
o Lower!body!segment!=!length!from!the!symphysis!pubis!to! children!can!do!at!a!certain!age!range%
the!floor% %
o Upper! body! segment! =! height! minus! the! lower! body! Factors%Affecting%Development%
segment% o Biological!Factors!
o Upper!Body:Lower!Body!Ratios% • Genes!!
• Birth:!1.7% • Proteins!produced!by!genes!
• 3!months:!1.3% • Biological!systems!
• 7!months:!Equal% o Environmental!Influence!
% • Culture!and!education!
Skeletal%Maturation% • Family!and!interpersonal!relations!
o Bone! age! correlates! well! with! stage! of! pubertal! • Environmental!toxins!
development% • Nutrition!
o More! closely! linked! to! sexual! maturity! than! chronological! %
age% %
o Useful!for!investigating!short!stature% %
o “Greulich!and!Pyle!method”!for!determining!bone!age% %
% %
TP
%
%
%
TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !1!!
Growth%Patterns%% !
o For!term!infants,!the!size!at!birth!reflects!the!uterine! !
environment!! !
o Between!5>18!months,!shifts!downwards!or!upwards! !
towards!genetic!potential!! !
o Thereafter!most!children!will!track!along!a!growth! !
percentile!between!two!large!centile!curves!corresponding! !
to!the!midparental!height!! !
• Boys:!(maternal!height!+!paternal!height!+!13!cm)/2!! !
• Girls:!(maternal!height!+!paternal!height!–!13!cm)/2!! !
o For!determining!predicted!adult!height!:!±10!cm!from!the! !
midparental!height!! !
! !
! !
! INFANCY%% TODDLERHOOD%% PRESCHOOL%% SCHOOL%AGE% ADOLESCENCE%
(0–1%YR)! (2–3%YR)! (3–6%YR)! (6–12%YR)! (12–20%YR)!
Freud:% Oral! Anal! Phallic/oedipal! Latency! Genital!
psychosexual!
Erikson:% Basic!trust!vs! Autonomy!vs!shame!and! Initiative!vs!guilt! Industry!vs! Identity!vs!role!
psychosocial! mistrust! doubt! inferiority! diffusion!
Piaget:% Sensorimotor! Sensorimotor! Preoperational! Concrete! Formal!
cognitive! operations! operations!
Kohlberg:% —! Preconventional:!avoid! Conventional:! Conventional:! Postconvention
moral! !! punishment/obtain! conformity!(stage!3)! law!and!order! al:!moral!
rewards!(stages!1!and!2)! (stage!4)! principles!
! !
Prenatal%Development% %
o Most! dramatic! events! in! growth! and! development! occur! %
before!birth.!! %
o Most!vulnerable!as!well,!since!the!uterus!is!permeable!to! %
adverse! social! and! environmental! influences! while! %
complex!processes!take!place.!! %
o The!interplay!of!forces!in!the!fetus!influences!the!infant’s! %
behavior! at! birth! and! may! affect! parent>child! interaction! %
throughout.!! %
% %
Fetal%Development%% %
o Embryonic! period:! 14! days! to! 8! weeks,! human>like! shape! %
attained! by! 4! weeks,! marked! by! the! development! of! %
rudiments!of!all!major!organ!systems.!! %
o Fetal!period:!9!weeks!onwards,!somatic!changes!consist!of! %
increasing!cell!number!and!size!and!structural!remodeling! %
of!organ!systems.!! %
o Brain! is! formed! at! birth! but! myelination! and! synaptic! %
organization!continues!post>natally!% %
% %
Pediatric%Age%Groups% %
o Neonate:!0>28!days! %
o Infancy:!0>2!years! %
o Preschool!Age:!2>5!years! %
o School!Age:!6>10!years! %
o Adolescence:!10>20!years% %
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TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !2!!
THE%FIRST%YEAR% AGE%6O12%MONTHS!
AGE%0O2%MONTHS% Physical%Development!
Physical%Development! o Growth! slows! more:! By! the! 1st! birthday,! birthweight! has!
o Birth! weight! decreases! by! 10%! in! the! first! week:! due! to! tripled,! length! has! increased! by! 50%,! and! head!
excretion! of! excess! extravascular! fluid! and! limited! circumference!has!increased!by!10!cm!
nutritional!intake.!! o Motor! achievements! correlate! with! increasing!
o Infants!regain!or!exceed!birthweight!by!2!weeks!of!age!! myelinization!and!cerebellar!growth!
o Grow! at! approximately! 30! g! (1! oz)/day! during! the! 1st! o Tooth! eruption! occurs,! usually! starting! with! the!
month.!(Period!of!fastest!postnatal!growth)!! mandibular!central!incisors!
o An!infant’s!preferential!turning!toward!the!mother’s!voice! %
is!evidence!of!recognition!memory.! Cognitive%Development!
! o The! complexity! of! an! infant’s! play,! how! many! different!
Cognitive%Development! schemata! are! brought! to! bear,! is! a! useful! index! of!
o Recognize!facial!expressions!(smiles)!as!similar,!even!when! cognitive!development!at!this!age!
they!appear!on!different!faces.!! o At! 9! months:! Object% permanence% (constancy):! the!
o Infants! at! 2! months! of! age! can! discriminate! rhythmic! understanding! that! objects! continue! to! exist,! even! when!
patterns!in!native!versus!non>native!language.!! not!seen.!!
o Infants! habituate! to! the! familiar,! attending! less! to! %
repeated! stimuli! and! increasing! their! attention! to! novel! Emotional%Development!
stimuli.! o Stranger% anxiety% develops:! Infants! look! back! and! forth!
! between! an! approaching! stranger! and! a! parent,! and! may!
Emotional%Development! cling!or!cry!anxiously!
o Basic!trust!versus!mistrust! o Tantrums! make! their! first! appearance! as! the! drives! for!
o Crying!occurs!in!response!to!stimuli!that!may!be!obvious!(a! autonomy! and! mastery! come! in! conflict! with! parental!
soiled!diaper),!but!are!often!obscure! controls!and!the!infants’!still>limited!abilities.!
o Infants! who! are! consistently! picked! up! and! held! in! !
response! to! distress! cry! less! at! 1! year! and! show! less! Communication!
aggressive!behavior!at!2!years.!! o Infants! at! 7! months! of! age! are! adept! at! nonverbal!
o Crying!normally!peaks!at!about!6!weeks!of!age! communication!
% o Social! interaction! (attentive! adults! taking! turns! vocalizing!
AGE%2O6%MONTHS! with!the!infant)!profoundly!influences!the!acquisition!and!
Physical%Development! production!of!new!sounds.!!
o Between! 3! and! 4! month,! the! rate! of! growth! slows! to! o The! first! true! word! appears! in! concert! with! an! infant’s!
approximately!20!g/day!! discovery!of!object!permanence.!!
o By!4!months,!birthweight!is!doubled! %
o Early!reflexes!that!limited!voluntary!movement!recede! %
• Disappearance!of!the!ATNR!allows!to!examine!objects! %
in!the!midline!and!manipulate!them!with!both!hands!! %
• Waning! of! the! early! grasp! reflex! allows! both! to! hold! %
objects!and!to!let!them!go!voluntarily! %
o Total!sleep!requirements!are!approximately!14>16!hour/24! %
hours,!(9>10!hours!concentrated!at!night!and!2!naps/day)! %
% %
Cognitive%Development! %
o At! 4! months! of! age,! infants! are! described! as! “hatching”! %
socially,!becoming!interested!in!a!wider!world! %
o Infants! at! this! age! also! explore! their! own! bodies,! staring! %
intently! at! their! hands,! vocalizing,! blowing! bubbles,! and! %
touching!their!ears,!cheeks,!and!genitals! %
o Infants! come! to! associate! certain! sensations! through! %
frequent!repetition! %
o The! sound,! smell,! and! feel! of! the! mother! sometimes! %
appear!promptly!in!response!to!crying,!but!sometimes!do! %
not! %
! %
Emotional%Development%and%Communication! %
o Babies! interact! with! primary! emotions! of! anger,! joy,! %
interest,!fear,!disgust,!and!surprise!! %
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TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !3!!
THE%SECOND%YEAR% Linguistic%Development!
AGE%12O18%MONTHS! o Child’s! vocabulary! balloons! from! 10>15! words! at! 18!
Physical%Development! months!to!between!50!and!100!at!2!years.!!
o Toddlers! have! relatively! short! legs! and! long! torsos,! with! o At!this!stage,!toddlers!understand!2Ostep%commands,%such!
exaggerated!lumbar!lordosis!and!protruding!abdomens! as!“Give!me!the!ball!and!then!get!your!shoes.”!!
o Most! children! begin! to! walk! independently! near! their! 1st! o Language!also!gives!the!toddler!a!sense!of!control!over!the!
birthday;! some! do! not! walk! until! 15!months! of! age! (Early! surroundings,!as!in!“night>night”!or!“bye>bye.”!!
walking! is! not! associated! with! advanced! development! in! o The! emergence! of! verbal! language! marks! the! end! of! the!
other!domains)! sensory>motor!period.!!
% %
Cognitive%Development! Developmental%Red%Flags%
o Exploration! of! the! environment! increases! in! parallel! with! o Concept!of!red!flags!–!warning!signs!!
o Limit!ages!!
improved! dexterity! (reaching,! grasping,! releasing)! and!
• Age!when!100%!of!a!particular!population!is!expected!
mobility.!!
to! exhibit! a! certain! milestone! at! a! certain! point! in!
o Learning! follows! the! precepts! of! Piaget’s! sensory>motor! time!
stage!! o Fine!Motor!
% • 3!1⁄2!months:!persistence!of!grasp!reflex!
Emotional%Development! • 7!months:!cannot!hold!an!object!with!each!hand!
o Toddlers! are! described! as! “intoxicated”! or! “giddy”! with! • 2!years:!!cannot!scribble!
their! new! ability! and! with! the! power! to! control! the! o !Gross!motor!!
• 4!1⁄2!months:!cannot!pull!up!to!sit!
distance!between!themselves!and!their!parents!!
• 5!months:!cannot!roll!over!
o Erikson’s!stage!of!autonomy!and!separation!!
• 9>10!months:!cannot!stand!holding!on!
! • 15!months:!!!cannot!walk!independently!
Linguistic%Development! o Receptive!Language!(Cognitive)!
o Receptive!language!precedes!expressive!language.!! • 2>3!months:!not!alert!to!mother!
o Toddlers! also! enjoy! polysyllabic% jargoning,! but! do! not! • 8>9!months:!no!interest!in!peek>a>boo!
seem!upset!that!no!one!understands.!! • 12!months:!!!doesn’t!search!for!hidden!object!
o Most! communication! of! wants! and! ideas! continues! to! be! o Expressive!Language!!
nonverbal.! • 5>6!months:!not!babbling!
• 18!months:!!less!than!three!words!with!meaning!
%
• 2!years:!no!two>word!phrases!
AGE%18O24%MONTHS!
o Social!!!
Physical%Development! • 3!months!not!smiling!reciprocally!
o Motor!development!is!incremental!at!this!age!! • 6>8!months:!not!laughing!at!playful!situations!
o Height! and! weight! increase! at! a! steady! rate! during! this! • 1!year:!hard!to!console!
year,!with!a!gain!of!5!in!and!5!lb!! • 2! years:! !no! eye! contact! or! engagement! with! other!
o By! 24! months,! children! are! about! half! of! their! ultimate! children!or!adult!
adult!height! %
!
Cognitive%Development!
o At!approximately!18!months!of!age,!object!permanence!is!
firmly!established!
o Cause!and!effect!are!better!understood,!and!demonstrate!
flexibility!in!problem!solving!!
o Cognitive! changes! at! 18! months! correlate! with! important!
changes!in!the!emotional!and!linguistic!domains!!
!
Emotional%Development!
o Rapproachment:! In! many! children,! the! relative!
independence! of! the! preceding! period! gives! way! to!
increased!clinginess!around!18!months!
o Separation%anxiety%will!be!manifest!at!bedtime!
o Many! children! use! a! special! blanket! or! stuffed! toy! as! a!
transitional% object,% which! functions! as! a! symbol! of! the!
absent!parent!
o Despite! the! attachment! to! the! parent,! the! child’s! use! of!
“no”!is!a!way!of!declaring!independence.!!
o Self>conscious! awareness! and! internalized! standards! of!
behavior!first!appear!at!this!age!
o Beginning!of!the!formation!of!a!conscience!
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TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !4!!
THE%PRESCHOOL%YEARS%
o 2>5!years!of!age!
o Emergence! of! language! and! exposure! to! an! expanding!
social!sphere!
o Explore! emotional! separation,! alternating! between!
stubborn!opposition!and!cheerful!compliance!
% o
Physical%Development!
o Somatic!and!brain!growth!slows!by!the!end!of!the!2nd!year!
of! life,! with! corresponding! decreases! in! nutritional!
requirements!and!appetite!!
o Emergence!of!“picky”!eating!habits!!
o Increases!of!~2!kg!(4>5!lb)!in!weight!and!7>8!cm!(2>3!in)!in!
height!per!years!are!expected!
o Birthweight!quadruples!by!2.5!years!of!age!
o Growth! of! sexual! organs! is! commensurate! with! somatic!
growth.!!
o Genu!valgum!(knock>knees)!and!mild!pes!planus!(flatfoot)!
are!present!
o Physical! energy! peaks,! and! the! need! for! sleep! declines! to!
11>13!hours/24!hours!
o Visual! acuity! reaches! 20/30! by! age! 3! years! and! 20/20! by!
age!4!years.!!
o All!20!primary!teeth!have!erupted!by!3!years!of!age!!
o Handedness%(3!years!of!age):!Frustration!may!result!from!
attempts!to!change!children’s!hand!preference!
o Bowel%and%bladder%control!
• Girls!tend!to!train!faster!and!earlier!than!boys!
• Bed>!wetting!is!normal!up!to!age!4!years!in!girls!and!
age!5!years!in!boys!!
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Language!
o Language!development!occurs!most!rapidly!
o Vocabulary! increases! from! 50>100! words! to! more! than!
2,000!
o Sentence!structure:!from%telegraphic%phrases%to%sentences%
incorporating%all%of%the%major%grammatical%components%
• By! 21! mo! to! 2! years,! most! children! are! using!
possessives,!progressives,!questions,!and!negatives!
• By!age!4!years,!most!children!can!count!to!4!and!use!
the!past!tense!
• By!age!5!years,!they!can!use!the!future!tense%%
o Between%the%ages%of%2%and%5%years,%the%number%of%words%in%
a%typical%sentence%equals%the%child’s%age%
o Language!acquisition!depends!on:!
• !Amount! and! variety! of! speech! directed! toward!
children!
• Frequency! with! which! adults! ask! questions! and!
encourage!verbalization!
o Language! delays:! first! indication! that! a! child! has! mental!
retardation,!has!an!autism!spectrum!disorder,!or!has!been!
maltreated!!
o Internalized! “private! speech”! in! which! a! child!!
repeats!adult!prohibitions,!first!audibly!and!then!mentally!
for!regulation!of!behavior!
o Period! of! rapid! language! acquisition:! Developmental%
dysfluency%and!stuttering%are!most!likely!to!emerge%
% o Curiosity! about! genitals! and! adult! sexual!
Cognition!
o Piaget’s! preoperational! (pre>logical)! stage,! characterized!
by! magical% thinking,! egocentrism,! and! thinking% that% is%
dominated%by%perception,!not!abstraction!or!logic!
TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !5!!
o Magical! thinking! includes! confusing! coincidence! with!
causality,! animism! (attributing! motivations! to! inanimate!
objects! and! events),! and! unrealistic! beliefs! about! the!
power!of!wishes!
o Egocentrism! refers! to! a! child’s! inability! to! take! another’s!
point!of!view!and!does!not!connote!selfishness!
Dominance!of!perception!over!logic!(water!is!poured!back!
and! forth! between! a! tall,! thin! vase! and! a! low,! wide! dish,!
and! children! are! asked! which! container! has! more! water.!
Invariably,!they!choose!the!one!that!looks!larger)!
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Play!
o Maria! Montessori! considered! play! to! be! the! work! of!
childhood!
o Play! involves! learning,! physical! activity,! socialization! with!
peers,!and!practicing!adult!roles!
o By!age!3!years,!cooperative!play!is!seen!in!activities!
o Play!also!becomes!increasingly!governed!by!rules:!
• 2!or!3!yr!of!age:!from!early!rules!about!asking!(rather!
than! taking)! and! sharing! (to! rules! that! change! from!
moment!to!moment!
• 4! and! 5! yr! of! age:! according! to! the! desires! of! the!
players!
• 5! yr! of! age! and! beyond! :! to! the! beginning! of! the!
recognition!of!rules!as!relatively!immutable!
o Play!also!allows!for!resolution!of!conflicts!and!anxiety!and!
for!creative!outlet!
o Themes! and! emotions! that! emerge! in! a! child’s! drawings!
often! reflect! the! emotional! issues! of! greatest! importance!
for!the!child!
Emotional%And%Moral%Development!
o Emotional!challenges:!
• Accepting! limits! while! maintaining! a! sense! of! self>
direction!
• Reining!in!aggressive!and!sexual!impulses!
• Interacting!with!a!widening!circle!of!adults!and!peers!!
o Excessively!tight!limits:!undermine!sense!of!initiative!!
o Overly!loose!limits:!anxiety!in!a!child!who!feels!that!no!one!
is!in!control!
o At!2!yr!of!age,!behavioral!limits!are!predominantly!external!
o By!5!yr!of!age,!these!controls!need!to!be!internalized!if!a!
child!is!to!function!in!a!typical!classroom!!
o Love!a!child!feels!for!important!adults!is!the!main!incentive!
for!the!development!of!self>control.!
o Control%is%a%central%issue.%%
o Tantrums!
• Normally!appear!toward!the!end!of!the!1st!year!
• Peak!in!prevalence!between!2!and!4!years!of!age!
• If!it!lasts!for!more!than!15!minutes!or!occurs!>3x!day!
may!reflect!underlying!problems!
o Preschool!children!normally!experience:!
• Strong! attachment! and! possessiveness! toward! the!
parent!of!the!opposite!sex!
• Jealousy!and!resentment!of!the!other!parent!
• Fear! that! these! negative! feelings! might! lead! to!
abandonment!
organs!is!normal,!as!is!masturbation!
o Moral%thinking%is!constrained!by!a!
TP
child’s! cognitive! level! and!
 language! abilities! (Beginning% before% the% 2nd% birthday,% the% % %
child’s% sense% of% right% and% wrong% stems% from% the% desire% to%
earn% approval% from% the% parents% and% avoid% negative%
consequences)!
o Fairness! is! taken! to! mean! equal! treatment,! regardless! of!
circumstance!
o Rules! tend! to! be! absolute,! with! guilt! assigned! for! bad!
outcomes,!regardless!of!intentions.!
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TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !6!!
MIDDLE%CHILDHOOD% o Beginning! in! the! 3rd! or! 4th! grade,! children! increasingly!
o 6>11!years!of!age! enjoy!strategy!games!and!wordplay!(puns!and!insults)!that!
o Previously!referred!to!as!latency! exercise!their!growing!cognitive!and!linguistic!mastery.!
o Children! increasingly! separate! from! parents! and! seek! %
acceptance!from!teachers,!other!adults,!and!peers! Social%and%Emotional%Development!
o SelfOesteem%becomes%a%central%issue% o Energy!is!directed!toward!creativity!and!productivity!
o Children! are! under! pressure! to! conform! to! the! style! and! o Central! Ericksonian! psychosocial! issue,! the! crisis! between!
ideals!of!the!peer!group! industry!and!inferiority!
! o Changes!occur!in!three!spheres:!the!home,!the!school,!and!
Physical%Development! the!neighborhood.!!
o Growth! averages! 3>3.5! kg! (7! lb)! and! 6>7! cm! (2.5! in)! per! • Home!and!family!remain!the!most!influential!
year!! • Increasing! independence! is! marked! by! the! 1st!
o Growth!occurs!discontinuously%(3>6!spurts!each!year)! sleepover!at!a!friend’s!house!or!at!overnight!camp!
o Myelinization!is!complete!by!7!years!of!age! • Siblings! have! critical! roles! as! competitors,! loyal!
o Body!habitus!is!more!erect!than!previously,!with!long!legs! supporters,!and!role!models!
compared!with!the!torso! o Social!groups!tend!to!be!same>sex,!with!frequent!changing!
o Loss! of! deciduous! (baby)! teeth! is! a! sign! of! maturation,! of!membership!
beginning!around!6!years!of!age!! o !Parents!may!have!their!greatest!effect!indirectly,!through!
• Replacement! with! adult! teeth! occurs! at! a! rate! of! actions! that! change! the! peer! group! (moving! to! a! new!
about!4!per!year! community!or!insisting!on!involvement!in!structured!after>
• Premolars!erupt!by!11>12!years!! school!activities).!
o Muscular! strength,! coordination,! and! stamina! increase! o Balance! between! fantasy! and! an! appropriate! ability! to!
progressively! negotiate! real>world! challenges! indicates! healthy!
o Sedentary!habits!at!this!age!are!associated!with!increased! emotional!development!
lifetime!risk!of!obesity!and!cardiovascular!disease! %
o Interest!in!gender!differences!and!sexual!behavior!remains! Moral%Development!
active! o By! the! age! of! 5! or! 6! years,! the! child! has! developed! a!
o Perception!of!body!image!(5>6!yrs!of!age)!and!may!already! conscience!
express!satisfaction/dissatisfaction! o Initially,!children!have!a!rigid!sense!of!morality,!relying!on!
% clear!rules!for!themselves!and!others.!!
Cognitive%Development! o By! age! 10! years,! most! children! understand! fairness! as!
o Children! increasingly! apply! rules! based! on! observable! reciprocity!(treat!others!as!you!wish!to!be!treated).!
phenomena,!and!interpret!their!perceptions!using!physical! o Useful!tools!to!asses!a!child’s!functioning!include:!
laws! • The! Draw>a>Person! (for! ages! 3>10! years,! with!
o Piaget! documented! this! shift! from! “preoperational”% to! instructions!to!“draw!a!complete!person”)!!
“concrete%logical%operations”! • Kinetic!Family!Drawing!(beginning!at!age!5!years,!with!
o The!concept!of!“school%readiness”%is!controversial! instructions! to! “draw! a! picture! of! everyone! in! your!
o By!age!5!years,!most!children!have!the!ability!to!learn!in!a! family!doing!something”)!
school!setting!! !
o Attention!span!at!least!45!minutes! !
o Separation! anxiety,! or! school! refusal,! is! common! in! the! !
early!school!years.! !
o The! first! 2! to! 3! years! of! elementary! school! is! devoted! to! !
acquiring! the! fundamentals:! reading,! writing,! and! basic! !
mathematics!skills! !
o Reading! a! paragraph! is! for! understanding! and! deduction! !
from!what!was!read! !
o Writing! is! done! to! check! the! composition,! sense! and! !
substance! !
o Classroom!performance!depends!on!these!factors:! !
• External! rewards! (eagerness! to! please! adults! and! !
approval!from!peers)! !
• Internal! rewards! (competitiveness,! willingness! to! !
work! for! a! delayed! reward,! belief! in! one’s! abilities,! !
and!ability!to!risk!trying!when!success!is!not!ensured)!

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TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !7!!
SELECTED%PERCEPTUAL,%COGNITIVE,%AND%LANGUAGE%PROCESSES%REQUIRED%FOR%ELEMENTARY%SCHOOL%SUCCESS%
PROCESS! DESCRIPTION! ASSOCIATED%PROBLEMS!
PERCEPTUAL%
Visual!analysis! Ability!to!break!a!complex!figure!into! Persistent!letter!confusion!(e.g.,!between!b,!d,!and!g);!
components!and!understand!their!spatial! difficulty!with!basic!reading!and!writing!and!limited!“sight”!
relationships! vocabulary!
Proprioception!and! Ability!to!obtain!information!about!body! Poor!handwriting,!requiring!inordinate!effort,!often!with!
motor!control! position!by!feel!and!unconsciously!program! overly!tight!pencil!grasp;!special!difficulty!with!timed!tasks!
complex!movements!
Phonologic!processing! Ability!to!perceive!differences!between!similar! Delayed!receptive!language!skill;!attention!and!behavior!
sounding!words!and!to!break!down!words!into! problems!secondary!to!not!understanding!directions;!
constituent!sounds! delayed!acquisition!of!letter>sound!correlations!
(phonetics)!
COGNITIVE%
Long>term!memory,! Ability!to!acquire!skills!that!are!“automatic”! Delayed!mastery!of!the!alphabet!(reading!and!writing!
both!storage!and!recall! (i.e.,!accessible!without!conscious!thought)! letters);!slow!handwriting;!inability!to!progress!beyond!
basic!mathematics!
Selective!attention! Ability!to!attend!to!important!stimuli!and! Difficulty!following!multistep!instructions,!completing!
ignore!distractions! assignments,!and!behaving!well;!problems!with!peer!
interaction!
Sequencing! Ability!to!remember!things!in!order;!facility! Difficulty!organizing!assignments,!planning,!spelling,!and!
with!time!concepts! telling!time!
LANGUAGE%
Receptive!language! Ability!to!comprehend!complex!constructions,! Difficulty!following!directions;!wandering!attention!during!
function!words!(e.g.,!if,!when,!only,!except),! lessons!and!stories;!problems!with!reading!
nuances!of!speech,!and!extended!blocks!of! comprehension;!problems!with!peer!relationships!
language!(e.g.,!paragraphs)!
Expressive!language! Ability!to!recall!required!words!effortlessly! Difficulty!expressing!feelings!and!using!words!for!self>
(word!finding),!control!meanings!by!varying! defense,!with!resulting!frustration!and!physical!acting!out;!
position!and!word!endings,!and!construct! struggling!during!“circle!time”!and!in!language>based!
meaningful!paragraphs!and!stories! subjects!(e.g.,!English)!
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TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !8!!
 EMERGING%PATTERNS%OF%BEHAVIOR%% AT%4%MONTHS%

NEONATAL%PERIOD%(1ST%4%WEEKS)% Gross%Motor:! Prone:!Lifts!head!and!chest,!with!head!in!

Prone:!Lies!in!flexed!attitude;!turns!head!from!side!
Gross%Motor:%
to!side;!head!sags!on!ventral!suspension!
Supine:!Generally!flexed!and!a!little!stiff!
May!fixate!face!on!light!in!line!of!vision;!“doll’s>
Fine%Motor:%
eye”!movement!of!eyes!on!turning!of!the!body!
Psychosocial:% Visual!preference!for!human!face!
Language:% Crying!
Reflex:% Moro!response!active;!stepping!and!placing!
reflexes;!grasp!reflex!active!
AT%1%MONTH%
Prone:!Legs!more!extended;!holds!chin!up;!turns!
Gross%Motor:!
head;!head!lifted!momentarily!to!plane!of!body!on!
ventral!suspension!
Supine:!Tonic!neck!posture!predominates;!supple!
and!relaxed;!head!lags!when!pulled!to!sitting!
position!
Fine%Motor:! Watches!person;!follows!moving!object!
Psychosocial:! Body!movements!in!cadence!with!voice!of!other!in!
social!contact;!beginning!to!smile!(reflex!smile)!
Language:% Alerts;!Throaty!gurgling!sounds!
AT%2%MONTHS%
Gross%Motor:! Prone:!Raises!head!slightly!farther;!head!sustained!
in!plane!of!body!on!ventral!suspension!
Supine:!Tonic!neck!posture!predominates;!head!
lags!when!pulled!to!sitting!position!
Fine%Motor:! Follows!moving!object!180!degrees!
Psychosocial:! Diminishes!activity!when!talked!to;!smiles!on!social!
contact!(social!smile)!
Language:% Listens!to!voice!and!coos!
! Vocalizes!
AT%3%MONTHS%
approximately!vertical!axis;!legs!extended!
Supine:!Symmetric!posture!predominates,!hands!in!
midline!
Sitting:!No!head!lag!when!pulled!to!sitting!position!
Fine%Motor:! Asymmetric!tonic!neck!reflex!and!palmar!grasps!
gone:!reaches!and!grasps!objects!and!brings!them!to!
mouth!
Adaptive:% Sees!pellet,!but!makes!no!move!to!reach!for!it!
Psychosocial:! May!show!displeasure!if!social!contact!is!broken!
Language:% Excited!at!sight!of!food;!Laughs!out!loud!
AT%7%MONTHS%
Gross%Motor:! Prone:!Rolls!over;!pivots;!crawls!or!creep>crawls!
Supine:!Lifts!head;!rolls!over;!squirms!
Sitting:!Sits!briefly,!with!support!of!pelvis;!leans!
forward!on!hands;!back!rounded!
Standing:!May!support!most!of!weight;!bounces!
actively!
Fine%Motor:! Reaches!out!for!and!grasps!large!object;!transfers!
objects!from!hand!to!hand;!grasp!uses!radial!palm!
Adaptive:% Rakes!at!pellet!
Psychosocial:! Prefers!mother;!babbles;!enjoys!mirror;!responds!
to!changes!in!emotional!content!of!social!contact!
Language:! Forms!polysyllabic!vowel!sounds!
AT%10%MONTHS%
Gross%Motor:! Creeps!or!crawls!
Sitting:!Sits!up!alone!with!back!straight!
Standing:!Pulls!to!standing!position;!“cruises”!or!
walks!holding!on!to!furniture!
Fine%Motor:! Grasps!objects!with!thumb!and!forefinger;!pokes!
at!things!with!forefinger;!picks!up!pellet!with!
assisted!pincer!movement;!uncovers!hidden!toy;!!

Gross%Motor:! Prone:!Lifts!head!and!chest!with!arms!extended;! Psychosocial:! Responds!to!sound!of!name;!plays!peek>a>boo!or!

head!above!plane!of!body!on!ventral!suspension! pat>a>cake;!waves!bye>bye!

Supine:!Tonic!neck!posture!predominates! Language:% Repetitive!consonant!sounds!(“mama,”!“dada”)!

Sitting:!Head!lag!partially!compensated!when! !
pulled!to!sitting!position;!early!head!control!with! AT%12%MONTHS%
bobbing!motion;!back!rounded!
Gross%Motor:! Walks!with!one!hand!held!(48!weeks);!rises!
Fine%Motor:! Grasps!rattle!at!3.5!months;!reaches!toward!and! independently,!takes!several!steps!
misses!objects;!waves!at!toy;!brings!hands!
Fine%Motor:! Picks!up!pellet!with!unassisted!pincer!movement!
together!in!the!midline!
of!forefinger!and!thumb;!releases!object!to!other!
Psychosocial:! Sustained!social!contact! person!on!request!or!gesture!
Language:% Listens!to!music;!Says!“aah,!ngah”! Psychosocial:! Plays!simple!ball!game;!makes!postural!adjustment!
Reflex:! Typical!Moro!response!has!not!persisted;!makes! to!dressing!
defensive!movements!or!selective!withdrawal! Language:% Says!a!few!words!besides!“mama,”!“dada”!
reactions!
!

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TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !9!!
 AT%15%MONTHS% AT%36%MONTHS%
Motor:! Walks!alone;!crawls!up!stairs! Motor:! Rides!tricycle;!stands!momentarily!on!one!foot!
Adaptive:! Makes!tower!of!3!cubes;!makes!a!line!with!crayon;! Adaptive:! Makes!tower!of!10!cubes;!imitates!construction!of!
inserts!raisin!in!bottle! “bridge”!of!3!cubes;!copies!circle;!imitates!cross!
Language:! Jargon;!follows!simple!commands;!may!name!a! Language:! Knows!age!and!sex;!counts!3!objects!correctly;!
familiar!object!(e.g.,!ball);!responds!to!his/her! repeats!3!numbers!or!a!sentence!of!6!syllables;!
name! most!of!speech!intelligible!to!strangers!
Social:% Indicates!some!desires!or!needs!by!pointing;!hugs! Social:% Plays!simple!games!(in!“parallel”!with!other!
parents! children);!helps!in!dressing!(unbuttons!clothing!
AT%18%MONTHS% and!puts!on!shoes);!washes!hands!
Motor:! Runs!stiffly;!sits!on!small!chair;!walks!up!stairs!with! AT%48%MONTHS%
one!hand!held;!explores!drawers!and!wastebaskets! Motor:! Hops!on!one!foot;!throws!ball!overhand;!uses!
Adaptive:! Makes!tower!of!4!cubes;!imitates!scribbling;! scissors!to!cut!out!pictures;!climbs!well!
imitates!vertical!stroke;!dumps!raisin!from!bottle! Adaptive:! Copies!bridge!from!model;!imitates!construction!of!
Language:! 10!words!(average);!names!pictures;!identifies!one! “gate”!of!5!cubes;!copies!cross!and!square;!draws!
or!more!parts!of!body! man!with!2!to!4!parts!besides!head;!identifies!
Social:% Feeds!self;!seeks!help!when!in!trouble;!may! longer!of!2!lines!
complain!when!wet!or!soiled;!kisses!parent!with! Language:! Counts!4!pennies!accurately;!tells!story!
pucker! Social:% Plays!with!several!children,!with!beginning!of!
AT%24%MONTHS% social!interaction!and!role>playing;!goes!to!toilet!
Motor:! Runs!well,!walks!up!and!down!stairs,!one!step!at!a! alone!
time;!opens!doors;!climbs!on!furniture;!jumps! AT%60%MONTHS%
Adaptive:! Makes!tower!of!7!cubes!(6!at!21!months);!scribbles! Motor:! Skips!
in!circular!pattern;!imitates!horizontal!stroke;!folds! Adaptive:! Draws!triangle!from!copy;!names!heavier!of!2!
paper!once!imitatively! weights!
Language:! Puts!3!words!together!(subject,!verb,!object)! Language:! Names!4!colors;!repeats!sentence!of!10!syllables;!
Social:% Handles!spoon!well;!often!tells!about!immediate! counts!10!pennies!correctly!
experiences;!helps!to!undress;!listens!to!stories! Social:% Dresses!and!undresses;!asks!questions!about!
when!shown!pictures! meaning!of!words;!engages!in!domestic!role>
AT%30%MONTHS% playing!
Motor:! Goes!up!stairs!alternating!feet! % !
Adaptive:! Makes!tower!of!9!cubes;!makes!vertical!and! !
horizontal!strokes,!but!generally!will!not!join!them! !
to!make!cross;!imitates!circular!stroke,!forming! !
closed!figure! !
!
Language:! Refers!to!self!by!pronoun!“I”;!knows!full!name!
Social:% Helps!put!things!away;!pretends!in!play!

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TP

TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%1%|! P a g e !10!!
 GROWTH%AND%DEVELOPMENT%%
Adolescent%Medicine%
%
ADOLESCENCE%VS%PUBERTY%
o Adolescence)is!defined!as!a!period!of!development;!!
o Puberty)is!the!biologic!process!in!which!a!child!becomes!an!
adult.!%
% characteristics!
EARLY%ADOLESCENCE%
Biologic%Development!
o In%girls%!
• First!visible!sign!of!puberty!and!the!hallmark!of!SMR2!
is!the!appearance!of!breast!buds!(8C12!years)!!
• Menses!typically!begins!2C2,5!years!after,!(SMR3C4)!!
• Less! obvious! changes! include! enlargement! of! the!
ovaries,! uterus,! labia,! and! clitoris,! and! thickening! of!
the!endometrium!and!vaginal!mucosa!
o In%boys!
• First!visible!sign!of!puberty!and!the!hallmark!of!SMR2!
is!testicular!enlargement!(9.5!years)!
• !This!is!followed!by!penile!growth!during!SMR3!!
• Under! the! influence! of! LH! and! testosterone,! the!
seminiferous! tubules,! epididymis,! seminal! vesicles,!
and!prostate!enlarge!!
• The!left!testis!normally!is!lower!than!the!right!
• Some! degree! of! breast! hypertrophy,! typically!
bilateral,!occurs!in!40C65%!of!boys!during!SMR2C3!due!
to!a!relative!excess!of!estrogenic!stimulation.!
o Peak!growth!velocities!are!reached!at!SMR3C4!
o Boys!typically!peak!2C3!yr!later!than!girls!
o Asymmetric! growth! spurt! begins! distally,! followed! by! the!
arms! and! legs,! and! finally,! the! trunk! and! chest! (gawky!
appearance)!!
o Rapid!enlargement!of!the!larynx,!pharynx,!and!lungs!leads!
to! changes! in! vocal! quality,! typically! preceded! by! vocal!
instability!(voice!cracking)!
o Elongation! of! the! optic! globe! often! results! in!
nearsightedness!
o Dental! changes! include! jaw! growth,! loss! of! the! final!
deciduous! teeth,! and! eruption! of! the! permanent! cuspids,!
premolars,!and!finally,!molars%
o Physical! maturation! correlates! with! sexual! maturity,!
whereas! psychosocial! development! correlates! more!
closely!with!chronological!age.%
% top!velocity!of!8.3!cm!(3.8!in)!per!year!and!then!slows!to!a!
Cognitive%and%Moral%Development%%
o Time! of! transition! from! concrete! operational! thinking! to!
formal!logical!thinking!(abstract!thought)!
o When!emotional!stakes!are!high,!adolescents!may!regress!
to!more!concrete!operational!and/or!magical!thinking!
o The! development! of! moral! thinking! roughly! but!
imperfectly!parallels!cognitive!development!
o Adolescent! decisionCmaking! remains! particularly!
susceptible!to!emotions.!
o It! is! unclear! whether! the! hormonal! changes! of! puberty!
directly!affect!cognitive!development.!!
o Related! to! neurobehavioral! maturation,! adolescents! may!
experience! an! increased! intensity! of! emotion! and/or!
greater! inclination! to! seek! experiences! that! create! such!
highCintensity!emotions!
% (approximately!50%)!
TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%2%|! P a g e !1!!
!
SelfPConcept!
o SelfCconsciousness! increases! exponentially! in! response! to!
the!somatic!transformations!of!puberty!!
o SelfCawareness! at! this! age! centers! on! external!
o Adolescents!use,!on!average,!7!hours!of!media!per!day!!
o This!exposure!may!cause!girls!to!develop!a!distorted!sense!
of! femininity,! and! they! may! be! at! risk! for! viewing!
themselves!as!overweight,!leading!to!eating!disorders!and!
depression!!
o Similarly,! boys! may! have! difficulties! with! selfCimage.!
Images! of! masculinity! may! be! confusing,! leading! to! selfC
doubt,!insecurity,!and!misleading!conceptions!about!male!
behavior%
%
Relationships%with%Family,%Peers,%and%Society!
o Less! interested! in! parental! activities! and! more! interested!
in!the!peer!group,!typically!with!peers!of!the!same!sex.!!
o Adolescents!also!seek!more!privacy,!which!may!contribute!
to!family!discord!
o Early!adolescents!often!socialize!in!sameCsex!peer!groups.!
Deepening! relationships! with! peers! contributes!
importantly! to! their! gradual! individuation! and!
independence!from!families!of!origin!!
o Female! friendships! may! center! on! emotional! intimacy,!
whereas!male!relationships!may!focus!more!on!activities.!
%
Sexuality%
o Anxiety! and! interest! in! sex! and! sexual! anatomy! increase!
during!early!puberty!!
o In!boys,!ejaculation!occurs!for!the!1st!time,!usually!during!
masturbation! and! later! as! nocturnal! emissions,! and! may!
be!a!cause!of!anxiety.!!
o Early! adolescents! sometimes! masturbate! together;!
isolated! incidents! of! mutual! sexual! exploration! are! not!
necessarily!a!sign!of!homosexuality%
%
MIDDLE%ADOLESCENCE!
Biologic%Development!
o Growth!accelerates!at!a!rate!of!6C7!cm!(3!in)!per!year!!
o In!the!average!girl,!the!growth!spurt!peaks!at!11.5!yr!at!a!
stop!at!16!yr!!
o In!the!average!boy,!the!growth!spurt!starts!later,!peaks!at!
13.5!yr!at!9.5!cm!(4.3!in)!per!year,!and!then!slows!to!a!stop!
at!18!yr.!!
o Lean!body!mass!increases!to!90%!in!boys!and!decreases!to!
75%!in!girls!as!subCcutaneous!fat!accumulates.!
o Physiologic! changes! in! sleep! patterns! and! requirements!
may!be!mistaken!for!laziness!
o Menarche!
• %Achieved! by! 30%! of! girls! by! SMR3! and! by! 90%! by!
SMR4!
• Follows! approximately! 1! yr! after! the! growth! spurt!
begins.!!
• Common!for!cycles!to!be!anovulatory!
C! 1st! 2! yr! after! menarche!
TP
 • Before! menarche,! the! uterus! achieves! a! mature!
configuration,! vaginal! lubrication! increases,! and! a!
clear! vaginal! discharge! appears! (physiologic!
leukorrhea)!
o In! boys,! the! phallus! lengthens! and! widens! during! SMR3,!
and!sperm!are!usually!apparent!in!semen.!
% propriety!
Cognitive%and%Moral%Development!
o Start!to!question!and!analyze!extensively!
o Questioning! of! moral! conventions! fosters! the!
development! of! personal! codes! of! ethics,! which! may! be!
similar!to!or!different!from!those!of!their!parents%
% Biologic%Development!
SelfPConcept!
o More! accepting! of! their! own! body! changes! and! become!
preoccupied!with!idealism!in!exploring!future!options.!!
o Affiliation! with! a! peer! group! is! an! important! step! in!
confirming!one’s!identity!and!selfCimage!
o Girls!may!tend!to!characterize!themselves!and!their!peers!
according!to!interpersonal!relationC!ships!(“I!am!a!girl!with!
close!friends”),!whereas!boys!may!focus!on!abilities!(“I!am!
good!at!sports”)%
% %
Relationships%with%Family,%Peers,%and%Society!
o !“Stereotypical!adolescence.”!!
o Relationships! with! parents! become! more! strained! and!
distant! due! to! redirected! energies! toward! peer!
relationships!and!separation!from!the!family!
o !Exploration!of!future!options,!they!begin!to!think!seriously!
about! what! they! want! to! do! as! adults,! a! question! that!
formerly!had!been!comfortably!hypothetical.!
%
Sexuality!
o Dating!becomes!a!normative!activity!to!assess!their!ability!
to!attract!others!
o Begin! to! sort! out! other! important! aspects! of! sexual!
identity,! including! beliefs! about! love,! honesty,! and!
o Relationships! at! this! age! are! often! superficial! and!
emphasize! attractiveness! and! sexual! experimentation!
rather!than!intimacy!
%
LATE%ADOLESCENCE!
o Modest!by!comparison!to!earlier!periods!
o The! final! stages! of! breast,! penile,! and! pubic! hair!
development!occur!by!17C18!yr!of!age!in!95%!of!males!and!
females!
o Minor! changes! in! hair! distribution! often! continue! for!
several! years! in! males,! including! the! growth! of! facial! and!
chest!hair!and!the!onset!of!male!pattern!baldness!in!a!few!
o Acne! occurs! in! the! majority! of! adolescents,! particularly!
males!
Psychosocial%Development!
o Cognition! tends! to! be! less! selfCcentered,! with! increasing!
thoughts! about! concepts! such! as! justice,! patriotism,! and!
history.!!
o More!constancy!in!their!emotions!
o Peer!group!and!peer!values!recede!in!importance!
o Relationships!increasingly!involve!love!and!commitment.!!
%

CENTRAL%ISSUES%IN%EARLY,%MIDDLE,%AND%LATE%ADOLESCENCE%
VARIABLE! EARLY%ADOLESCENCE!
Sexual!maturity! 1C2!
rating*!
Somatic! Secondary!sex!characteristics!
Beginning!of!rapid!growth!
Awkward!appearance!
Cognitive!and!moral! Concrete!operations!Unable!to!
perceive!longCterm!outcome!of!
current!decisionCmaking!
Conventional!morality!
SelfCconcept/identity! Preoccupied!with!changing!body!
formation! SelfCconsciousness!about!
appearance!and!
attractiveness!Fantasy!and!
presentCoriented!
Family! Increased!need!for!privacy!
Increased!bid!for!independence!
Peers! Seeks!sameCsex!peer!affiliation!to!
counter!instability!
Sexual! Increased!interest!in!sexual!
anatomy!Anxieties!and!questions!
about!genital!
changes,!size!Limited!dating!and!
intimacy!
Relationship!to! Middle!school!adjustment!
society!
MIDDLE%ADOLESCENCE!
3C5!
Height!growth!peaks!Body!shape!and!
composition!change!Acne!and!odor!
Menarche/spermarche!
Emergence!of!abstract!thought!(formal!
operations)!
May!perceive!future!implications,!but!
may!not!apply!in!decisionCmaking!
Questioning!mores!
Concern!with!attractiveness!Increasing!
introspection!“Stereotypical!
adolescent”!
Conflicts!over!control!and!
independence!Struggle!for!acceptance!
of!greater!autonomy!
Intense!peer!group!involvement!
Preoccupation!with!peer!culture!Peers!
provide!behavioral!example!
Testing!ability!to!attract!
partner!Initiation!of!relationships!and!
sexual!activity!Questions!of!sexual!
orientation!
Gauging!skills!and!opportunities!
LATE%ADOLESCENCE!
5!
Physically!mature!Slower!
growth!
FutureCoriented!with!sense!of!
perspective!Idealism;!
absolutism!Able!to!think!things!
through!independently!
More!stable!body!image!
Attractiveness!may!still!be!of!
concern!Emancipation!
complete!Firmer!identity!
Emotional!and!physical!
separation!from!family!
Increased!autonomy!
Peer!group!and!values!recede!
in!importance!
Intimacy/possible!commitment!
takes!precedence!
Consolidation!of!sexual!
identity!Focus!on!intimacy!and!
formation!of!stable!
relationships!Planning!for!
future!and!commitment!
Career!decisions!(e.g.,!college,!
TP
work)!

TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%2%|! P a g e !2!!
!
%
CLASSIFICATION%OF%SEX%MATURITY%STATES%IN%BOYS% CLASSIFICATION%OF%SEXUAL%MATURITY%STATES%IN%GIRLS%
SMR% PUBIC%HAIR! PENIS! TESTES! SMR% PUBIC%HAIR! BREASTS!
STAGE! STAGE!
1! None! Preadolescent!
1! Preadolescent! Preadolescent!
2% Scanty,!long,! Minimal! Enlarged!
slightly!pigmented! change! scrotum,!pink,! 2! Sparse,!lightly! Breast!and!papilla!elevated!
texture!altered! pigmented,!straight,! as!small!mound;!diameter!
3! Darker,!starting!to! Lengthens! Larger! medial!border!of! of!areola!increased!
curl,!small!amount! labia!
4! Resembles!adult! Larger;!glans! Larger,!scrotum! 3! Darker,!beginning! Breast!and!areola!enlarged,!
type,!but!less! and!breadth! dark! to!curl,!increased! no!contour!separation!
quantity;!coarse,! increase!in!
amount!
curly! size!
4! Coarse,!curly,! Areola!and!papilla!form!
5! Adult! Adult!size! Adult!size!
distribution,! abundant,!but!less! secondary!mound!
spread!to!medial! than!in!adult!
surface!of!thighs! 5! Adult!feminine! Mature,!nipple!projects,!
% triangle,!spread!to! areola!part!of!general!
medial!surface!of! breast!contour!
%
thighs!
%
BRIGHT%FUTURES%ADOLESCENT%SCREENING%RECOMMENDATIONS%
! 11P14%YEAR%OLD%VISIT! 15P17%YEAR%OLD%VISIT! 19P21%YEAR%OLD%VISIT!
UNIVERSAL%SCREENING% ACTION% ACTION% ACTION%
Vision!(once!during!each!of!3!adolescent! Snellen!test! Snellen!test! Snellen!test!
age!groups)!
Dyslipidemia!(once!in!late!adolescence)! NA! NA! Fasting!lipid!profile!
SELECTIVE% RISK%ASSESSMENT% ACTION!IF!RA+! ACTION!IF!RA+! ACTION!IF!RA+!
SCREENING%
Vision!at! +!on!risk!screening! Snellen!test! Snellen!test! Snellen!test!
other!ages! questions!
Hearing! +!on!risk!screening! Audiometry! Audiometry! Audiometry!
questions!
Anemia! +!on!risk!screening! Hemoglobin!or! Hemoglobin!or!hematocrit! Hemoglobin!or!hematocrit!
questions! hematocrit!
Tuberculosis! +!on!risk!screening! Tuberculin!skin!test! Tuberculin!skin!test! Tuberculin!skin!test!
questions!
Dyslipidemia! +!on!risk!screening! Lipid!screen! Lipid!screen! Lipid!screen!if!not!age!20,!+!
questions!and!not! on!risk!screening!questions!
previously!screened! and!not!previously!screened!
with!normal!results! with!normal!results!
STIs! Sexually!active! Chlamydia!and! Chlamydia!and!gonorrhea! Chlamydia!and!gonorrhea!
gonorrhea!screen!(use! screen!(use!tests! screen!(use!tests!appropriate!
tests!appropriate!for! appropriate!for!population! for!population!and!clinical!
population!and!clinical! and!clinical!setting)! setting)!
setting)!
Sexually!active!and!+! Syphilis!test!HIV!test*! Syphilis!test!HIV!test*! Syphilis!test!HIV!test*!
on!risk!screening!
questions!
Pregnancy! Sexually!active,!without! Urine!hCG! Urine!hCG! Urine!hCG!
contraception,!late!
menses!or!amenorrhea!
Cervical! NA! NA! NA! Pap!smear,!conventional!slide!
dysplasia†! or!liquidCbased!at!age!21!yr!
Alcohol!or! +!on!risk!screening! Administer!alcohol!and! Administer!alcohol!and! Administer!alcohol!and!drug!
drug!use! questions! drug!screening!tool! drug!screening!tool! screening!tool!
%
%
% %

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TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%2%|! P a g e !3!!
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ADOLESCENT%INTERVIEW%AND%PHYSICAL%EXAMINATION%
Interviewing%the%Adolescent!
o Issues! of! confidentiality! and! privacy! should! be! explicitly!
stated! along! with! the! conditions! under! which! that!
confidentiality! may! need! to! be! altered,! that! is,! in! lifeC! or!
safetyCthreatening!situations.!
o For!new!patients,!the!parents!should!be!interviewed!with!
the!adolescent!or!before!the!adolescent!to!ensure!that!the!
adolescent!does!not!perceive!a!breach!of!confidentiality.!
o The! use! of! openCended! questions,! rather! than! closedC
ended!questions,!will!further!facilitate!history!taking.!!
o The!adolescent!should!be!given!an!opportunity!to!express!
concerns!and!the!reasons!for!seeking!medical!attention.!!
! ageCspecific! norms! that! increase! with! pubertal!
Psychosocial%Assessment!
o The! HEADS/SF/FIRST% mnemonic,! basic! or! expanded,! can!
be! useful! in! guiding! the! interview! if! encounter! forms! are!
not!available!!
o Based! on! the! assessments,! appropriate! counseling! or!
referrals!are!recommended!for!more!thorough!probing!or!
for!inCdepth!interviewing.!
% males!
Table!106C4%HEADS/SF/FIRST%
Home.!Space,!privacy,!frequent!geographic!moves,!
neighborhood.!
Education/School.!Frequent!school!changes,!repetition!of!a!
grade/in!each!subject,!teachers’!reports,!vocational!goals,!afterC
school!educational!clubs!(language,!speech,!math,!etc.),!learning!
disabilities.!
Abuse.!Physical,!sexual,!emotional,!verbal!abuse;!parental!
discipline.!
Drugs.!Tobacco,!alcohol,!marijuana,!inhalants,!“club!drugs,”!
“rave”!parties,!others.!Drug!of!choice,!age!at!initiation,!
frequency,!mode!of!intake,!rituals,!alone!or!with!peers,!quit!
methods,!and!number!of!attempts.!
Safety.!Seat!belts,!helmets,!sports!safety!measures,!hazardous!
activities,!driving!while!intoxicated.!
Sexuality/Sexual%Identity.!Reproductive!health!(use!of!
contraceptives,!presence!of!sexually!transmitted!infections,!
feelings,!pregnancy)!
Family%and%Friends.%Family:!Family!constellation,!genogram,!
single/married/!separated/divorced/blended!family,!family!
occupations!and!shifts;!history!of!addiction!in!1stC!and!2ndC
degree!relatives,!parental!attitude!toward!alcohol!and!drugs,!
parental!rules;!chronically!ill!physically!or!mentally!challenged!
parent.!Friends:!peer!cliques!and!configuration!(“preppies,”!
“jocks,”!“nerds,”!“computer!geeks,”!cheerleaders),!gang!or!cult!
affiliation.!
Image.!Height!and!weight!perceptions,!body!musculature!and!
physique,!appearance!(including!dress,!jewelry,!tattoos,!body!
piercing!as!fashion!trends!or!other!statement).!
Recreation.!Sleep,!exercise,!organized!or!unstructured!sports,!
recreational!activities!(television,!video!games,!computer!games,!
Internet!and!chat!rooms,!church!or!community!youth!group!
activities![e.g.,!Boy/Girl!Scouts;!Big!Brother/!Sister!groups,!
campus!groups]).!How!many!hours!per!day,!days!per!week!
involved?!
Spirituality%and%Connectedness.!Use!HOPE*!or!FICA†!acronym;!
adherence,!rituals,!occult!practices,!community!service!or!
involvement.!
Threats%and%Violence.!SelfCharm!or!harm!to!others,!running!
away,!cruelty!to!animals,!guns,!fights,!arrests,!stealing,!fire!
setting,!fights!in!school.!
*HOPE:! hope! or! security! for! the! future;! organized! religion;! personal!
spirituality!and!practices;!effects!on!medical!care!and!end!of!life!issues.!
†
FICA:! faith! beliefs;! importance! and! influence! of! faith;! community!
support.!
TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%2%|! P a g e !4!!
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PHYSICAL%EXAMINATION!
o Audiometry!
• Highly! amplified! music! of! the! kind! enjoyed! by! many!
adolescents!may!result!in!hearing!loss!
o Vision%Testing!
• The! pubertal! growth! spurt! may! involve! the! optic!
globe,! resulting! in! its! elongation! and! myopia! in!
genetically!predisposed!individuals!
• Vision! testing! should,! therefore,! be! performed! in!
order! to! detect! this! problem! before! it! affects! school!
performance!
o Blood%Pressure%Determination!
• Criteria!for!a!diagnosis!of!hypertension!are!based!on!
maturation!!
• An!individual!whose!blood!pressure!exceeds!the!95th!
percentile! for! his! or! her! age! is! suspect! for! having!
hypertension,!regardless!of!the!absolute!reading.!
o Scoliosis%!
• Manifested! during! the! peak! of! the! height! velocity!
curve,!at!approximately!12!yr!in!females!and!14!yr!in!
• Curves!measuring!greater!than!10!degrees!should!be!
monitored! by! an! orthopedist! until! growth! is!
complete.!
o Breast%Examination%
• Detect! masses,! evaluate! progression! of! sexual!
maturation,!provide!reassurance!about!development,!
and!teach!the!technique!of!selfC!examination!with!the!
hope! that! this! practice! will! continue! into! the! higher!
risk!later!years.!!
o Scrotum%Examination!
• The!peak!incidence!of!germ!cell!tumors!of!the!testes!
is!in!late!adolescence!and!early!adulthood!
• Palpation!of!the!testes!may!have!an!immediate!yield!
and! should! serve! as! a! model! for! instruction! of! selfC
examination!
o Laboratory%Testing!
• Increased! incidence! of! ironCdeficiency! anemia! after!
menarche!mandates!the!performance!of!a!hematocrit!
annually! in! young! women! with! moderate! to! heavy!
menses.!!
• Tuberculosis! testing! on! an! annual! basis! is! important!
in! adolescents! with! risk! factors,! such! as! an! adolesC!
cent! with! HIV,! living! in! the! household! with! someone!
with! HIV,! the! incarcerated! adolescent,! or! those! with!
other! risk! factors,! because! puberty! has! been! shown!
to! activate! this! disease! in! those! not! previously!
treated!
• Hepatitis! C! virus! screening! should! be! offered! to!
adolescents!who!report!risk!factors,!such!as!injection!
drug!use,!received!blood!products!or!organ!donation!
before! 1992,! longCterm! hemodialysis,! or! high!
prevalence! setting! (i.e.,! correctional! facilities! or! STI!
clinics).!
• Sexually!active!adolescents!should!undergo!screening!
for!STIs!regardless!of!symptoms!!
! !
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TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%2%|! P a g e !5!!
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 TP

TPMD%2017|PEDIATRICS%1%–%Growth%and%Development%2%|! P a g e !6!!
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 PEDIATRIC%HISTORY%AND%PHYSICAL%EXAMINATON%
%
PEDIATRIC%HISTORY%% o Associated!symptoms!!
o Often!obtained!from!a!person!other!than!the!patient!! • Onset,!course,!intensity!!
! o Pertinent!negatives!!!
GENERAL%PRINCIPLES%IN%PEDIATRIC%HISTORYGTAKING%AND%PE%% o If! readmission! or! with! OPD! work?up,! get! summary! of!
o Observe!patient!as!soon!as!patient!enters!your!clinic.!!! previous!confinement!or!OPD!visit!and!start!HPI!from!here,!
o In!emergency,!PE!and!urgent!therapeutic!measures!should! followed!by!interval!history!!!
be!initiated!while!trying!to!extract!histories.!!! !
o Examine! immediately! patients! who! are! ill?looking! or! in! REVIEW%OF%SYSTEMS%%
distress!to!determine!need!for!immediate!action.!!! o Elaborate! symptoms! (not! PE! findings)! in! systems! not!
o Flexible! and! opportunistic! approach,! leaving! unpleasant! covered!in!the!HPI!
procedures!last.!!! o To!uncover!symptoms!in!other!organs!or!systems!that!may!
o Use! play! activities! to! assess! patient’s! condition! and! to! be!related!to!the!HPI!!
distract!children!to!reduce!anxiety.!!! o Symptoms!should!be!age?specific!!
o PE!should!be!complete.!!! o General:!weight!loss/gain,!activity!level,!appetite,!delay!in!
! growth!
% o Cutaneous:!rash,!pigmentation,!hair!loss,!pruritus,!etc.!!
% o HEENT:! headache,! dizziness,! visual! difficulties,!!
% lacrimation,! deafness,! otalgia,! ear/nasal! discharge,!
% epistaxis,!sore!throat,!etc.!!
% o Cardiovascular:! orthopnea,! cyanosis,! easy! fatigability,!
% fainting!spells!!
% o Respiratory:!chest!pain,!cough,!dyspnea!!
% o GIT:! nausea,! vomiting,! bowel! movement,! diarrhea,!
% constipation,! encopresis,! passage! of! worms,! abdominal!
% pain,!jaundice,!food!intolerance,!pica,!etc.!!
% o GUT:! frequency,! volume,! color! of! urine,! discharge,!
THE%ART%OF%COMMUNICATION%IN%HISTORYGTAKING%%% enuresis,!dysuria,!etc.!!
o Establish!eye!contact!!! o Endocrine:!pain!or!discharge,!breast!asymmetry,!cold/heat!
o Listen!attentively!!! intolerance,!3!P’s!!
o Ask!open?ended!questions!!! o Nervous/behavioral:! tremors,! sleep! problems,!
o Let!caretakers!narrate!the!story!of!the!illness!!! convulsions,! weakness! or! paralysis,! mental! deterioration,!
o Avoid!asking!leading!questions!!! personality/behavioral,!mood!changes,!etc.!!
! o Musculoskeletal:! bone! and! joint! pain! or! swelling,!
GENERAL%DATA%% limitation!of!motion,!limping!!
o Name!!! o Hematopoietic:! pallor,! bleeding! manifestations,! easy!
o Age/!birth!date!!! bruisability!!
o Sex/Gender!!! !
o Race!(ethnicity)!!! PERSONAL%HISTORY%%
o Birthplace!!! o Gestational*%
o Religion!!! • Mother’s! age,! parity,! health,! infections,! drug! intake,!
o Address!!! x?ray!exposures,!age!of!gestation!!!
o No.!and!dates!of!previous!hospitalizations!!! o Birth*%%
o Informant!and!reliability!! • Term,! pre?! or! post?term,! type! of! delivery! by! whom!
! and!where,!birth!weight!!!
CHIEF%COMPLAINT%% o Neonatal*%%
o “Why!was!the!patient!brought!to!the!hospital”!!! • APGAR! score,! spontaneous! cry,! jaundice,!
o May!be!a!symptom!or!group!of!related!symptoms!!! hemorrhages,! congenital! anomalies,! cyanosis,! pallor,!
o Avoid!diagnosis!!! birth!injuries!!!
! o Feeding*History*in*Infancy*%%
HISTORY%OF%PRESENT%ILLNESS%(HPI)%%% • Type! of! feeding:! breastfeeding,! exclusive! or! mixed,!
o Signs!and!symptoms!in!chronological!order!!! frequency,! duration! per! breast,! formula! type,!
o Elaborate!symptoms!! dilution,! amount! per! feeding! and! per! day,! bottle! or!
• Onset,! intensity,! interference! with! activity,! quality,! cup!feeding!!!
location,!duration,!extent,!severity,!and!frequency!! • Complementary!foods:!age!introduced,!type,!!
o Aggravating!or!relieving!factors!!! • Usual! food! intake! for! 3! major! meals! and! snacks;!
o Medications!!! assess! if! 5! basic! food! groups! are!
• Generic,!(brand)!names!! eaten!daily!!!
• Actual!dose!in!mg/kg/day!or!mg/kg/dose!! • Compute! for! actual! caloric! TP
• Duration!of!treatment!! intake! and! compare! with!

TPMD%2017|PEDIATRICS%1%–%History%and%Physical%Examination%|! P a g e !1!!
!
 recommended! energy! and! nutrient! intake! with! the! PHYSICAL%EXAM%IN%PEDIATRICS%%
food!guide!pyramid!!! o Adapt!to!the!situation!!
• Food!intolerance!!! o Leave!the!more!unpleasant!or!uncomfortable!parts!last!!
• Multivitamin!and!iron!supplements!!! o Examine!patient!with!minimum!of!clothing!on,!if!possible!!
! o Distract!patients!to!allay!fear!!
o Feeding*history*in*childhood*&*adolescence** o Use!play!activites!as!part!of!pediatric!examination!!
• Appetite!! o May! have! to! examine! infants! &! children! while! being!
• Usual!food!intake!&!amount!per!day!for!the!3!major! carried!by!guardians!!
meals!&!snacks!! o Immobilize! unruly! or! uncooperative! patients! to! facilitate!
• Assess!if!5!basic!food!groups!are!eaten!regularly!! PE!or!diagnostic!procedures!&!to!prevent!injuries!!
• Compute! for! actual! caloric! intake! &! compare! with! !
recommended!energy!&!nutrient!intake!with!the!food! GENERAL%SURVEY%%
guide!pyramid!! o Mental!state!or!sensorium!!
• Food!likes!or!dislikes,!feeding!difficulties! o Level!of!activity!!
• Multivitamin!&!iron!supplements!! o With!cardiopulmonary!distress!or!not!!
! o Color!!
o Developmental/Behavioral** o Ambulatory!or!bedridden!!
• Young!children!(1?5!years!old):!! o Nutritional!state!(well,!under!or!over!nourished)!!
→ Check! development! using! modified! o State!of!hydration!!
developmental!checklist!in!appendix!! o Ill!looking!or!not!!
→ Dental!eruption!! !
VITAL%SIGNS%%
→ Other! problems! like! urinal! incontinence,! toilet!
o Temperature! preferably! by! axillary! route;! avoid! rectal!
training,! temper! tantrums,! head! banging,!
route! as! infant! may! sit! up! on! his! own;! preferably! use!
phobias,!pica,!night!terrors,!sleep!disturbances!!
digital!thermometer!
• Infants!&!young!children!(0?6!years!old):!!
o Pulse!rate!
→ Preferably!do!Denver!II!
o Respiratory!rate!
• Middle!childhood!to!adolescence!!
o Blood!pressure!if!greater!than!3!years!old!!
⇒ School!performance!!
BP!Cuff!Bladder!!
⇒ Adolescence!(10?18!years!old):HEEADSSSS!!
• Cuff!should!be!~!2/3!of!upper!arm!length!&!80?100%!
!
of!arm!circumference!!
PAST%MEDICAL%HISTORY%
!
o Contagious!diseases!!
ANTHROPOMETRIC%DATA%%
o Other!medical!illnesses,!hospitalizations,!surgeries!
o 3!major!growth!parameters!!
o Allergies! to! food! /! drugs! /! environmental! allergens,!
• Weight,!!in!kg!
eczema,!asthma!!
• Length!for!children!<!2!years!old;!Height!for!≥!2!years!
o Injuries!!
old,!in!cm!
%
• Head!circumference,!in!cm!
Immunization%history:%%
• Chest!circumference,!in!cm!!
o Types!of!immunization!
o Age!when!given!! • Abdominal!circumference!in!cm!!
o Where!given,!by!whom!! • Arm! span! &! U/L! ratio! for! children! with! growth!
o Any!adverse!reactions!! disorders!!
! o Measuring!head!circumference!!
FAMILY%HISTORY:%% • Tape! measure! placed! over! the! supraorbital! ridge! in!
o Parents:!age,!occupation,!state!of!health,!if!deceased,!age! front! &! extended! circumferentially! to! include! the!
&!cause!of!death;!history!of!consanguinity!! most!prominent!part!of!the!occiput!
o Siblings:!number,!ages,!state!of!health;!if!deceased,!age!&! o Measuring!chest!circumference!!
cause!of!death!! • Done! at! mid?inspiration,! with! xiphoid! notch! as!
o Familial!illnesses!or!anomalies!! reference!point!!
! o Measuring!abdominal!circumference!!
SOCIOECONOMIC%HISTORY:%% • Measure!across!umbilicus!in!infants!!
o Living! circumstances:! place! &! nature! of! dwelling,! number! • In! older! children,! reference! point! is! between! lowest!
of!persons!living!in!the!house!! rib!&!the!iliac!crest!!
o Economic! circumstances:! members! of! family! who! work,! o Measuring!arm!span!!
sources!of!funds!! • With! arms! outstrectched! sidewise! parallel! to! the!
! ground! and! palms! facing! front,! measure! from! tip! of!
ENVIRONMENTAL%HISTORY:%% the!R!to!the!L!middle!finger!!
o Exposure! to! cigarette! smoke! &! other! environmental! !
pollutants!! !
o Garbage!and!sewage!disposal!! !
TP
o Water!source!! !

TPMD%2017|PEDIATRICS%1%–%History%and%Physical%Examination%|! P a g e !2!!
!
o Measurement!of!lower!&!upper!body!segments!!
• Lower!body!segment!!
→ 0?3! years! old:! measure! with! child! supine,! from!
umbilicus!to!tip!of!toes!with!feet!flexed!at!90º!at!
the!heel!!
→ 3! years! old:! with! child! standing,! measure! from!
superior!iliac!spine!to!the!floor!!
• Upper! body! segment:! length! or! height! –! lower! body!
segment!!
• Normal!values!for!U/L!ratios!!
→ At!birth:!1.7!!
→ 1!month!?!3!years!old:!1.3!!
→ >!3!years!old:!1!! !
o Body%Mass%Index%% %
% EAR%AND%MASTOID%EXAMINATION%%
o Size,!shape,!location!&!position!of!the!ear!in!relation!to!the!
HEAD%AND%FACE%EXAMINATION%
o Hair:! quantity,! color,! texture,! surface! characteristics,! rest!of!the!head!!!
o How!to!determine!low!set!ears:!!!
strength!!
o Abnormal!swelling:!cephalhematoma,!caput!succedaneum,! • Draw!a!line!from!the!lateral!canthus!of!both!eyes!!
hematoma,!abscess,!tumors,!angioedema!! • Normal:!20%!of!the!pinna!should!be!above!that!line!!
o Unusual!shapes!! o Low!set!ears:!
o Palpate! the! fontanel! in! the! upright! position,! or! with! the! • Formofdysmorphism!!
head!supported!in!a!semiupright! • Seen!in!some!chromosomal!abnormalities!!
o Inspect! for! symmetry,! expression,! unsual! facies,! o Note! for! ear! discharge,! purulent! (otitis! media)! or! watery!
deformities,!lumps!&!bumps!! (ex.!CSF!in!cases!of!head!trauma)!or!bloody!!!
% o Inspect! also! postauricular! and! mastoid! areas! for! any!
EYE%EXAMINATION% swelling!or!signs!of!inflammation!!!
o Lids,! Conjunctivae,! Sclerae,! Pupils! ,! Extraocular! • Any! chronic! ear! infection! can! affect! the! bone! by!
movements!,!Vision,!Strabismus,!Opacities,!Discharge,!Red! contiguity!!
orange!reflex!(ROR),!Corneal!light!reflex!,!Cross?cover!test! o Otoscopic! set! &! pneumatic! bulb! needed! for! internal!
% examination!
% !
% Otoscopy%%
o Insert!otoscope!with!appropriate!angle!in!to!the!ear!canal!
depending! on! age! of! patient! due! to! anatomical!
differences.!!
• In!newborns/infants:!direction!of!ear!canal!is!upward!
–! therefore! pull! pinna! downwards! and! posteriorly! to!
straighten!the!ear!canal!to!visualize!ear!drum!!
• In! older! children:! direction! of! ear! canal! is! downward!
and! forward! –! thus,! pinna! should! be! pulled! upwards!
and!back!!
• The!direction!you!pull!the!pinna!must!be!opposite!to!
the!anatomical!orientation!of!the!ear!canal.!!
o The! speculum! should! be! inserted! into! the! canal! in!
corresponding!direction!“looking!your!way”!in.!!!
o Proper!way!of!handling!otoscope:!!!
• Hold!handle!like!holding!a!pen!!
Corneal%light%reflex%(Hirschberg%test)%% • The!knuckles!of!the!hand!holding!the!otoscope!must!
o Target!object!is!held!14?16”!in!front!of!the!child!! be! touching! the! cheek! of! the! patient! to! stabilize!
o Position! child! so! that! the! penlight,! target! object! &! otoscope! and! prevent! you! from! inserting! otoscope!
examiner’s!line!of!vision!are!at!the!same!level!as!the!child’s! too! much! inside! ear! canal! which! may! cause!
eyes!! discomfort!and!pain.!!
o Shine! penlight! from! above! the! target! object! towards! o Cone!of!light!seen!at!the!tip!of!the!handle!of!the!malleolus!
center!of!forehead!just!above!the!eyes!! (umbo)!–!normal!!
o Note!reflections!of!the!light!on!the!cornea.!! • If!you!do!not!see!the!COL!=!abnormal!eardrum!!
o Asymmetric!reflections!suggest!eso!or!exotrophia!! o Opaque,! glistening! with! intact! cone! of! light! =! normal!
! TM!Pneumatic! otoscopy! will! demonstrate!
! mobility! of! TM;! it! should! be! able! to!
! move! when! you! apply! positive!
! TP
and!negative!pressure!!
!
TPMD%2017|PEDIATRICS%1%–%History%and%Physical%Examination%|! P a g e !3!!
!
 • When! you! press! pneumatic! bulb! =! positive! pressure!
(TM!must!move!inwards!–!concave)!!
• When! you! release! the! bulb! =! negative! pressure! (TM!
will!move!towards!opposite!side)!!
o Impaired!mobility!when!there!is!increased!pressure!in!the!
middle!ear!!
• Ex.!in!cases!of!effusions,!inflammation!!
o Abnormal!otoscopic!findings!!
• Acute!otitis!media:!hyperaemic!with!no!cone!of!light!!
• AOM! with! clear! effusion! and! air:! bubbles! are! seen!
with!half!of!ear!almost!opaque!!
• AOM! with! purulent! effusion:! yellowish! o! Bullous!
myringitis:!see!bullae!o!With!perforation:!end!stage!of!
AOM!
• ! !
! o Posterior% pharyngeal% wall:! note! if! with! cobblestone!
! appearance! which! is! due! to! hypertrophy! of! lymph! nodes;!
NOSE%EXAMINATION%
o Check! for! patency! of! the! nares,! alar! flaring! (child! in!
respiratory! distress),! presence! &! character! of! discharge!
(watery,!bloody,!purulent),!position!of!septum!(midline!or!
deviated),! sinus! tenderness! (medial! supraorbital! ridge,!
lateral!sides!of!nose,!and!maxillary!area)!!
• Unilateral! nose! discharge! usually! associated! with!
foreign!bodies!!
o Nasal!findings!and!clinical!correlates!!
• Nasal!crease!!
→ Seen!in!patient!with!allergic!rhinitis!because!they!
keep!on!wrinkling!their!nose!!
• Nasal!polyps!!
→ Also!in!patient!with!allergic!rhinitis!!
• Pale! violaceous! nasal! mucosa! (pale! and! boggy!
turbinates)!!
→ In!infections,!it!would!be!hyperaemic.!!
• Adenoid!facies!!
→ Dry! tongue! and! lips! usually! !because! they! have!
adenoidal! hypertrophy! so! they! have! chronic!
nasal!congestion!=!mouth!breathers!!!
→ Other! allergic! markers:! Demi! Morgan! folds,!
allergic!shiners,!etc!!!
%
%
%
TPMD%2017|PEDIATRICS%1%–%History%and%Physical%Examination%|! P a g e !4!!
!
%
MOUTH%AND%THROAT%EXAMINATION%
o Lips:! check! for! color! (cyanotic,! pink),! moisture,!
excoriations! (micronutrient! deficiencies),! clefts! (lip! or!
palate)!!!
o Throat:!To!minimize!use!of!tongue!depressor,!ask!patient!
!to! say! “aaaah”.! Inspect! anterior! structures! then! the!
tongue! and! under,! then! the! posterior! structures! using!
tongue!depressor.!Use!bright!light.!!!
o Gums:! check! color,! continuity! (stomatitis,! inflammation),!
bleeding,!hypertrophy!(diseases!and!medication?related)!!!
o Tongue:!size!(macroglossia),!moisture,!color!&!consistency,!
coatings! (milk! curds! vs! oral! candidiasis),! markings!
(geographic! tongue! –! normal;! smooth! tongue! –! iron!
deficiency),! ankyloglossia,! ulcers,! abnormal! movements!
(chorea! form! movements! in! tongue,! signs! of! denervation!
like!fasciculations!are!best!seen!here)!!!
o How%to%use%tongue%depressors%when%examining%tongue%%
• Immobilize!child!if!uncooperative!!!
• Hold!tongue!depressor!with!dominant!hand,!penlight!
!with!the!other!hand!!!
• The!4th!and!5th!fingers!of!the!dominant!hand!should!
!rest! on! the! chin! or! face! so! that! the! hand! can! move!
!along!even!when!the!child!moves!his!face!!!
• Tip! of! the! tongue! depressor! is! placed! at! the! center!
and!at!the!junction!of!the!anterior!2/3!and!posterior!
1/3! of! the! tongue,! pressing! the! tongue! downward!
!firmly!to!get!a!good!view!of!the!oropharynx!!!
!
Examination%Of%The%Throat%
o Palate%and%uvula:%note!symmetry,!presence!of!cleft,!rash,!
vesicles!(rashes!in!mucosa!due!to!varicella),!ulcers,!thrush,!
high!arch!(type!of!dysmorphism!also)!!!
postnasal!drippings!!!
o Dentition:% there! are! 20! milk! teeth! by! 2! years! old,! note!
color,!pitting!of!enamel,!dental!caries!!!
o Tonsils:! presence! or! absence,! surface! color,! exudates!
(acute! tonsillopharyngitis,! post?! streptococcal! infections),!
adherent!membrane!(from!diphtheria)!!!
• Correlate!size!with!age.!Tonsils!often!appear!big!from!
toddler! to! school! age.! Beyond! this! age,! it! should!
diminish!in!size.!!
%
Grading*Tonsillar*Size**
Occupying! <! 25! %! of! the! posterior!
1+!!
pharyngeal!width!!
Occupying! <! 50! %! of! the! posterior!
2+!!
pharyngeal!width!!
Occupying! <! 75! %! of! the! posterior!
3+!!
pharyngeal!width!!
4! +! (kissing! Occupying!>75!%!of!the!posterior!pharyngeal!
tonsils)!! width!!
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 %
CHEST%EXAMINATION%
o Inspection%
• Check! for! deformities! (pectus! carinatum,! pectus!
excavatum,!etc)!!
• Chest!circumference!(CC)!<!head!circumference!in!the!
first!9?12!months!of!life!!
• After! 1! year! old,! chest! circumference>head!
circumference!
• Anteroposterior!diameter:!
→ In! infancy,! AP! diameter! =! transverse! diameter!
(they!appear!to!be!barrel!chested)!!
→ After! 2! years! old,! transverse! diameter! >! AP!
diameter!(same!in!mature!chest!configuration)!!
→ Barrel! chest! in! asthma! (AP! =! TD;! due! to! chronic!
%
obstructive!airway!disease!and!air!trapping)!!
%
Examination%Of%The%Oral%Mucosa% • Respirations:!!
o Healthy!oral!mucosa!is!often!pinkish!reddish.!! → Newborns! &! young! infants:! mostly! abdominal!
o Congestion!or!erythema!should!be!redder!than!usual! breathing!because!they!rely!on!their!diaphragm!!
(compare!with!other!parts!of!the!mucosa)!! → After! 4?5! years! old:! mostly! due! to! intercostal!
o When! assessing! tonsils! &! posterior! pharyngeal! wall! muscles!!
congestion,!they!should!be!compared!with!the!rest!of!the! • Retractions:! subcostal,! intercostal,! supraclavicular!
oral!mucosa!! (signs!of!respiratory!distress)!!
o Geographic! tongue:! NORMAL!?! Milk! curds! vs.! Oral! • Note!for!symmetry!in!chest!expansion!!
Candidiasis!! → Check!for!lagging!!
• Milk! curds! can! be! wiped! off! easily! with! gauze! or! o Palpation%%
tongue!blade!–!disappear!! • Vocal!fremitus!!
• If! candidiasis,! when! you! try! to! wipe! it! off,! it! will! → Do! especially! if! there! are! abnormal! chest!
produce!a!raw!red!surface!! findings!!!
! → Child! is! asked! to! repeat! “tres! tres”! or! “ninety!
NECK%EXAMINATION% nine”! while! examiner! palpates! all! areas! of! the!
Note!for!the!following:! chest!and!!back.!!!
o Venous!engorgement!! → Palmar! or! ulnar! surface! of! both! hands! should!
o Flexibility!! detect! !distinct! vibrations! of! equal! intensity! on!
o Rigidity!! corresponding!areas!of!2!sides!of!chest!
o Masses!(check!in!midline!and!other!triangles!of!neck)! !
o Lymph!nodes!! Implications*of*abnormal*fremitus*findings**
o Acanthosis!nigricans!!
Fremitus%
• Hyperpigmentation! found! on! nape;! appear! velvety;! Clinical%implications%%
findings%%
seen! in! obese! patients! (at! risk! for! insulin! resistance!
Atelectasis! (due! to! collapse! of! lung),!
and!metabolic!syndrome)!!
Decrease!! pneumothorax! (air! in! pleural! cavity! outside! lung),!
* pleural!effusion!!
Goiter*Grading*System*(WHO)**
Consolidation! (increased! transmission! of! sound!
0!!! No!goiter!! Increase!!
from!solid!to!solid)!!!
Ia!! Goiter! detectable! by! palpation! &! not! visible!
!
!! when!neck!is!fully!extended!!
o Percussion%
Goiter!palpable!but!visible!only!when!the!neck! Implications*of*variations*in*percussion*notes**
Ib!!
is!fully!extended!!
Nature% of%
! Goiter! is! visible! when! neck! is! in! normal! ! underlying% Clinical%implications%%
II!! structures%%
position!!
!! Normal!
III!! Very! large! goiter! that! can! be! recognized! at! a! Resonant%% Normal!!
chest!!
!! glance!!
Solid! Consolidation! or! over! the!
! Dull%%
structures!! liver!!
Thyroid! gland! must! be! palpated! and! should! move! with!
Fluid! filled!
deglutition.!! % Pleural!effusion!!
areas!!
!
Pneumothorax,!
% Hollow! or!
emphysema;! maybe!
% Hyperresonant%% airfilled!
expected! in! young! infants!
% areas!!
with!thin!chest!wall!!
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TPMD%2017|PEDIATRICS%1%–%History%and%Physical%Examination%|! P a g e !5!!
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o Auscultation% !CARDIOVASCULAR%EXAMINATION!
Normal*breath*sounds** o Inspection%%
Heard!over!midline,!elsewhere!it!is! • Precordium:!adynamic!or!dynamic!!!
Bronchial%%
pathologic!! • Look! for! visible! pulsations! over! various! parts! of! the!
Vesicular%% Normally! heard! over! chest,! axilla! !chest!&!in!the!epigastrium!!!
! and!infrascapular!areas!! • Apex! beat! corresponds! to! the! lower! and! outermost!
Mixed! because! the! chest! wall! of! !point!of!the!cardiac!impulse!!
infants!are!very!small.!So!bronchial! • Normally!located!at!the!4th!LICS!MCL!(before!7!years!
sounds! are! easily! transmitted! to! old)!
Bronchovesicular%! th
the!lung!parenchyma! • Shifts!to!the!5 !LICS!MCL!at!7!years!old!!
Heard! more! on! infants! with! thin! *
chest!wall!! Clinical*implications*of*chest*findings**
! PE%findings%% Clinical%implications%%
Abnormal*or*adventitious*breath*sounds* Adynamic!
Breath%sounds%% Pathology%% I%or%E%% Implication%%
Pericardial!effusion!!
precordium!!
% Coarse! (lower! inflammation,% Fever,! hyperthyroidism,! increase! volume!
CRACKLES%% pitched)!or!fine!! edema,% or%
Hyperdynamic! load! as! in! L! to! R! shunt,! hypertension,!
! When! an! infection!!
precordium!! impending!heart!failure,!maybe!normal!in!a!
Explosive! non>! obstructed! Early:!bronchitis!
musical! sounds! lumen! suddenly! Both% I% &% or!asthma!! thin!patient!!
occurring! in! opens!&!the!! E!! Mid:! Apex! beat!
burst! like! pressure!either! bronchiectasis!! displaced!
Cardiac!enlargement!!
popping! of! side! of! the! Late:! interstitial! laterally! and!
bubbles!! obstruction! lung! disease,! inferiorly!!
! equilibriates!on!! CHF!pneumonia%!
Apex! beat!
!
displaced! to! Dextrocardia!!
WHEEZES%%
the!right!!
Continuous!
Turbulent! flow! Obstructive% Precordial!
musical! sounds! Cardiomegaly!!
in! narrow! Usually%E%% airway% disease;%
that!can!be!high! bulge!!
airways!! CHF%%
pitched! w/! a! %
whistling! o Palpation%
quality! • Thrills:! purring! vibratory! sensation! felt! by! the! palm!
Low! pitched!
placed!over!the!precordium;!“Palpable!murmurs”!?!!
RHONCHI%% with! a! snoring%
Presence! of! • Substernal% thrust:! presence! of! right! ventricular!!
Coarse! or% moaning%
Usually%E%% secretions! in! volume!or!pressure!overload!(ex.!heave)!!
“wheeze”! that! quality;!also!felt!
! !! larger! airways! Variations%in%pulse%findings%%
are!continuous! by! palpating!
as!in!bronchitis%!
!! palms! &! clear% Decrease% Pericardial! ventricular! obstruction,!
on%coughing!! pulse% in% all% cardiomyopathy!!
Hollow! sound! extremities%% tamponade,!L!outflow!dilated!!
transmitted!by!!
Aortic! run?off! lesion! like! PDA,! AV! mal,!
sound!from! Consolidation%% Bounding%%
BRONCHIAL% increase!CO!due!to!anemia,!thyrotoxicosis!!
trachea!through! Usually%I%% usually! in! the!
/TUBULAR%% RadialG
the! upper!lobes!!
consolidated! femoral%
chest!wall!area!! delay,% absent%
Coarctation!of!aorta!!
PLEURAL% or% weak%
Produced! by!
FRICTION%RUB%% Both% I% &% femoral%
friction! of! the! Pleurisy%%
Rubbing! E% pulses%%
pleural!surfaces!!
leathery!sound*
%
Monophasic!
o Auscultation%%
noise;! usually!
Upper% airway% Grading*of*intensity*of*murmur**
STRIDOR%% audible% even% Usually%I%%
obstruction%% o Grade!I:!barely!audible!!
w/o%
stethoscope!! o Grade!II:!medium!intensity!!
Defense% o Grade!III:!loud!but!NO!thrill!!
mechanism% of% Usually! in! o Grade!IV:!louder!with!thrill!!
GRUNTING%
the% child! to! restrictive% lung% o Grade! V:! loud! &! audible! with! stethoscope! barely! on! the!
Physiologic! end!
raise! FRC! by! diseases! to!
expiratory! Usually%E%% chest!!
closing! the! prevent!
pressure!! o Grade!VI:!audible!w/!stethoscope!off!the!chest!!
glottis! at! the! collapse!!
%% !
end! of! !%
expiration;!! !
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ABDOMINAL%EXAMINATION% o Indirect/rebound! tenderness! is! present! when! pain! is!
o Inspection! present! or! more! severe! on! release! of! fingers! from!
• Size,! shape,! presence! of! prominent! vessels,! striae,! abdomen;!signifies!peritoneal!irritation.!!!
pulsations,!peristaltic!movements,!hernia! !
Clinical*implications*of*abdominal*findings** Examining%the%Spleen%%%
% o Have!patient!lie!on!supine!!!
Diaphragmatic! hernia! in! newborn!
Scaphoid%or%flat%% o Palpate! from! RLQ! ?>! L! costal! margin! using! R! hand! as!
(abdominal!organs!in!pleural!cavity)!!
%% patient!inspires!deeply!!!
Normal!in!infants!and!toddlers!(due!to! o L!hand!lift!L!rib!cage!&!flank!!
weak! abdominal! musculature,! o When! palpable,! the! spleen! slides! downward! during!
Full,% globular,% relatively! large! abdominal! organs! &! inspiration!and!upward!during!expiration!!
protuberant%% lumbar!lordosis)!! • If! you! can! palpate! the! spleen! even! without! this!
In! other! instances,! think! of! 5! Fs! (fat,! technique,!think!of!splenomegaly.!!
fetus,!feces,!fluids,!flatus)!! o Presence! of! splenic! notches! on! medial! surface! helps!
Maybe! normal! in! thin! patient!May! you!identify!the!spleen!!
Peristaltic%waves%% signify! presence! of! obstruction! in! !
pyloric!stenosis,!intusussception!! Examining%the%Spleen:%Castel%Method%%
Distended% veins% o To!detect!mild!splenomegaly!!!
(collateral% blood% In! epigastric! areas,! may! indicate! o Have!patient!lie!supine!!!
vessels% seen% in% obstruction!of!inferior!vena!cava!! o Percuss!lowest!ICS!along!L!anterior!axillary!line!!!
portal%HPN)%% o Normally!resonance!is!noted!!!
Paradoxical% o If! +! splenomegaly,! dullness! is! noted! on! deep!
Diaphragmatic! paralysis! or! impending! !inspiration!!
abdominal%
respiratory! failure! in! severe! status! Caution!in!splenomegaly:!Heavy!pressure!!during!
movements% w/% •
asthmaticus!! palpation!may!cause!splenic!rupture!!
breathing%%
! !
o Palpation! Palpation%of%Kidneys%%%
• Have!patient!lie!supine!semiflexed!at!hips!and!knees!!! o Have!patient!lie!supine!!!
• If!right!hand!palpates,!stand!on!R!side!of!patient!!! o Place! palm! of! one! hand! posteriorly! at! the! flank,!
• Warm!palms!by!rubbing!against!each!other!!! !pushing!the!kidneys!forward!!!
o Place! the! other! hand! anteriorly! below! the! costal!
• Distract!the!child!while!attempting!to!palpate!!!
!margin,! push! the! abdominal! wall! backwards! and!
• In! ticklish! children,! place! your! hand! over! child’s!
!upwards!!!
fingers!with!fingers!overlapping!the!child’s.!press!both!
o !Kidneys! are! best! felt! at! deep! inspiration! but! are!
the!child’s!and!your!fingers!over!the!abdomen!!!
!FIXED! and! DO! NOT! MOVE! with! respiration! –! helpful!
• Ask!patient!to!inhale!deeply!!!
in!identifying!kidney!!
• Use!flat!side!of!fingers!to!palpate!!!
!
• In!crying!infants,!lay!hand!on!abdomen!&!when!infant!
Elicitation%of%CVA%tenderness%%%
!inhales! deeply! after! a! long! cry,! press! fingers! to!
o Done!only!in!older!children!and!adolescents!!!
palpate!!
o Have!patient!sit!up!on!examining!table!!!
!
o Use!heel!of!closed!fist!(ulnar!side)!to!strike!the!patient!
Extent%of%lower%liver%edge%in%young%infants%and%children!!
!firmly! on! the! CVA! (angle! between! 12th! rib! and!
o In! young! infants! and! children,! liver! is! normally!
transverse!process!of!upper!lumbar!verterbrae)!!!
palpable! below! R! subcostal! margin! as! following:! (cm!
!
below!RSC!along!RMCL)!!*
Inguinal%regions%%%
• 0?6!months!–!3?3.5!
Common!causes!of!swelling!!
• 6!months!–!4!years!old!–!0?3!
o Hydrocoele!!
• 4?10!years!old!–!<2!
o Inguinal! hernias:! usually! enlarge! when! child! cries! or!
• >10!years!old!–!<1! strains!and!get!smaller!when!the!child!quiets!down!!
o Beyond!this!values,!think!of!hepatomegaly!! o Lymph!nodes!!
! !
Palpating%painful%abdomen%% %
o Ask!the!child!to!pinpoint!the!site!of!maximal!pain!!! %
o Start! palpating! AWAY! from! the! site! of! pain! slowly! %
!inching!toward!painful!area!!! %
o Watch!facial!expression!when!palpating.!!! %
• Wincing,!grimacing,!or!sudden!cry!on!palpation!is! %
strongly!suggestive!of!underlying!pathology!!! %
o Direct! tenderness! is! present! if! noted! on! direct! %
pressure!!! %
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MALE%GENITALIA%EXAMINATION% EXAM%OF%ANUS%%
o Prepuce!should!be!easily!retractable!!! o Place!child!in!L!lateral!decubitus!w/!legs!flexed!against!the!
o Phimosis!is!present!if!the!preputial!sac!is!very!narrow!!and! abdomen!(fetal!position)!to!expose!anus!!!
cannot!be!retracted!!! o Look! for! location,! patency,! fissures,! tags,! hemorrhoids,!
• Physiologic!in!infancy!and!early!childhood!! presence!of!pinworms,!prolapse!etc!!!
• By!age!3,!you!can!already!retract!prepuce!easily.!! !
o Urethra!should!open!at!the!tip!of!the!penis.!! RECTAL%EXAM%–%if%history%indicates%it%%%
• If!under:!hypospadia!! o Have!child!in!L!lateral!decubitus!with!R!leg!drawn!up!!into!
• If!on!dorsal!surface:!epispadia!! his/her!abdomen!and!head!curled!down!(fetal!!position)!!!
o Left!side!of!scrotum!usually!at!a!lower!level!than!right!but! o Use! gloved! index! finger! in! older! children! and! little! !finger!
!should!be!of!equal!size!!! in!young!infants!for!digital!exam!!!
o If! unequal,! the! larger! side! may! be! abnormal! due! to! o Apply!lubricant!on!finger!tip!befor!inserting!finger!!!
!hydrocoele,!hernia,!or!enlarged!testes!! o Assess! sphincter! tone,! presence! of! mass,! or! !impacted!
• The!smaller!side!maybe!associated!with!!absent!testis! feces!and!tenderness!!!
or!nondescent!(cryptochordism)! !
! EXAMINATION%OF%THE%EXTREMITIES%%%
Assessing*testicular*volume*** o Check!for!clubbing!!!
o Prader’s! orchidometer! is! used! to! measure! testicular! o Schamroth’s! sign:! loss! of! the! diamond! shaped! !window!
volume!!! between!finger!nail!beds!!!
o The! following! formula! can! be! used! to! estimate! testicular! o In!clubbing,!you!don’t!have!the!window!!!
volume:!(L!x!W)!/!2!!! !
o Normal!values:!!! SCREENING%FOR%SCOLIOSIS%%%
• 1?3!ml:!prepubertal!! o Note!symmetry!of!shoulder,!shoulder!blades!and!hips!!
• 12?25ml:!adults!! o Scoliotic:!grossly!deviated!thoracolumbar!spine,!
! asymmetrical!hips!!
Differences*between*hydrocoele*and*hernia** o Milder!scoliosis:!cannot!see!when!px!is!upright!o!Do!a!
Transillumination%% bend!forward!test!!
! Pathology%% (putting% light% o Bend!forward,!ask!child!to!place!palms!over!knees!!
behind%scrotum)%% !
Fluid! enters! through! LYMPH%NODE%REGIONS%
Hydrocoele%% (+)!! o Check!for!enlargement,!tenderness,!inflammation!!!
processus!vaginalis!!
o ! Palpable!LN:!!!
Abdominal! contents!
Hernia%% enter! through! (?)!! • Submandibular!!
processus!vaginalis!! • Submental!!
% • Anterior!cervical!!!
FEMALE%GENITALIA%EXAMINATION% • Axillary!!
o Extra! care! when! doing! exam! of! female! genitalia! in! • Popliteal!!
children!! • Femoral!!
o Explain!to!patient!or!caretaker!first!!! • Inguinal!!
o Have!patient!in!frog!leg!position!!! • Epitrochlear!!
o Examine!vulvovaginal!area!first!!! • Infraclavicular!!
o Then!knee!chest!position!with!valsalva!maneuver,!!inspect! • Posterior!cervical!!
lower!1/3!of!the!vagina!!! • Suboccipital!!
o Gentle! traction! of! the! labia! upward! and! outward! helps! • Posterior!auricular!!
!expose!the!vaginal!introitus!for!assessment!!! • Preauricular!!
o Presence!of!discharge!or!laceration!should!be!noted!!! !
o Note! that! normal! hymen! may! appear! in! different!
!variations!(ie,!imperforate,!microperforate,!septate)!!!
• In!infants,!mother!can!assist!in!doing!the!procedures!
o Do!Tanner!scoring!!!
!
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 PEDIATRIC%NEUROLOGIC%HISTORY%AND%EXAMINATION%
%
NEUROLOGIC%HISTORY% Does%the%Child%have%a%neurological%problem?%
o The!primary!problem!of!the!child!is!embodied!in!the!!chief! o Signs!and!Symptoms!of!increased!ICP!
complaint.! o Signs!and!Symptoms!of!Meningeal!irritation!
o Complaints!and!disease!progression!points!to!a!pathology!! o Signs! and! Symptoms! of! neurologic! deficits! which! includes!!
in!a!particular!!neuroanatomic!circuit:!! the!presence!of!!delays,!arrest!or!regression!of!previously!
! Mental! acquired!milestones.!
! Motor! %
! Sensory% Unquestionably%Neurologic%
% o Altered!sensorium!
MENTAL%SIGNS%AND%SYMPTOMS%% o Seizures!
o Alterations!in!consciousness! o Developmental!delays!/!regression!
! Lethargy,!Coma! o Language!problems!
! Seizures! o Disorders!of!!cognitive!function!
! Attention!Deficit! %
o Cognitive!Dysfunction! NEUROLOGIC%HISTORY%
! Retardation/!Dementia! o An! accurate! history! from! the! members! of! the! family! is!
! Impaired!!Judgement! essential!in!neurologic!evaluation!
! Dyscalculia/!Dysphasia/Agnosia! o Include! the! patient! himself,! surprisingly,! if! properly!
o Affective!Dysfunction! questioned,!a!child!of!3!to!5!!years!may!provide!invaluable!
% information!(may!be!more!reliable)!
MOTOR%SIGNS%AND%SYMPTOMS%% • No!!leading!questions!!
o Somatomotor! • Interview! ! depends! on! his! mood,! stop! if! fatigued! or!
! Weakness! restless!
! Abnormalities!in!!tone! • In!younger!child!or!limited!attention!span,!the!salient!
! Incoordination! points!of!the!history!are!best!obtained!at!the!onset!of!
! Involuntary!movements! evaluation!
o Visceromotor!/!Homeostatic! o Developmental%milestones%must%always%be%recorded!
! Cardiovascular! o Review!of!system!focuses!on!the!major!childhood!illnesses,!
! Bowel/Bladder! immunizations!(reactions),!injuries,!etc.!
! Sweat!pattern! • Frequent! injuries! suggest! hyperactivity! or! poor!
coordination!!
! Sexual!dysfunction!
o Family! history! (consanguinity,! similar! or! other! neurologic!
%
or!developmental!problems)!
SENSORY%SIGNS%AND%SYMPTOMS%% o The!following!4!questions!should!be!answered!if!possible,!
o Deficits!of!sensation! in!taking!the!history!of!current!illness:!
! Anesthesia/!hypesthesia/numbness! • Is!the!process!acute!or!insiduous?!
! Visual!dysfunction! • Is!it!focal!or!generalized?!
! Deafness/!Hyperacusis! • Is!it!progressive!or!static?!
! Anosmia!
• At!what!age!did!the!problem!begin!
o Excessive!Sensation!
o Identifying%the%Children%at%Risk!
! Pain! • Necessitates! the! survey! of! antenatal,% perinatal% and%
! Neuralgia! postnatal%events!
! Hyperesthesias! → Duration! of! the! pregnancy,! complications,!
! Dizziness! illnesses,!drug!intake,!etc!
! Tinnitus! → Delivery,! resuscitation,! Apgar! scores,! and! other!
% markers!of!!asphyxia!
→ Immediate! and! the! remainder! of! the! newborn!
NEUROLOGIC%HISTORY%
period!
Goals!of!answering!the!following:!
• Feeding!history!!
o Is!there!a!neurologic!disorder?! • Unusual!sleep!patterns!
o If!so,!where!is!the!lesion,!or!as!the!case!in!many!pediatric! !
neurologic!cases,!does!it!involve!all!parts!of!the!brain!to!an! %
equal!degree?! %
o What!pathologic!lesions!are!most!likely!to!produce!lesions! %
at!this!site!or!sites?!! %
%
o The! course! of! the! illness! (acute,! subacute,! static,! or!
%
remitting)!may!provide!clues!to!nature% %
% %
% %
% % TP
% %

TPMD%2017|PEDIATRICS%1%–%Neurological%History%and%Examination%|! P a g e !1!!
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% %
PHYSICAL%AND%NEUROLOGICAL%EXAMINATION!
General%Physical%Examination!
o Anthropometric!!!!measurements!
o Vital!signs!
o General!appearance!!/!dysmorphism!
o Examination! of! ! the! skin! /! neurocutaneous! stigmata! –!
hemangiomas,café!au!lait,!hypopigmented!macules!
o Teeth!(antenatal!reasons,!hyperbilirubinemia)!
o Palmar!creases!
o Observe%for%Dysmorphic%features%
• Eyes!–!hypo/hypertelorism!
% • Ears^!low!set!or!malformed!
• Chin!^!micrognathia!
• Mouth!–!macrostomia,!open!mouth!
• Neck!–!webbed,!short!!!!
• Hairline!/!Hair!whorls!!
• Eyebrows!^!synophrys!
o Inspection!
• Quality!of!scalp!hair,!eyebrows,!and!nails!
• Corneas!and!lenses!for!opacities!
• Inspect! the! midline! of! the! neck,! back,! and! pilonidal!
areas!
• Compare!thumb!nail!sizes!and!convexity!Heart,!chest!
and!abdominal!exam,!and!palpation!of!femoral!pulses!
• Unusual!body!odors!
o Palpation%
• Cranial!Sutures!and!Fontanels!
• Head! circumference! (! serial):! for! assessing!
hydrocephalus!or!!microcephaly!!
• Tenderness!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
• MacEwen!sign!(!cracked!pot!sound)!
o Head:%Inspect,%Palpate,%Percuss!
• Appearance!of!the!head!can!suggest!
o Macrocephaly!(open!and!large!fontanels)!
o Microcephaly!(closed!fontanels)!
o Craniosynostosis!(palpable!ridgy!sutures)!
% o Venous! distention! suggesting! increased!
intracranial!pressure!
• Flattened!!occiput!suggest!a!developmentally!delayed!
child!!
• Bulging!occiput!suggest!a!Dandy^Walker!cyst!
• Biparietal! (Devil’s! horns)! enlargement! suggest!
bilateral!chronic!subdural!hematomas!
o Recording% of% findings% must% be% in% systematized% order% to%
include:%
• Mental!status!
Cranial!nerves!
• Motor!(gait,!tone,!bulk,!power)!
• Coordination!
% • Reflexes!
• Sensory!!
• Autonomic!
!
Mental%Status%–%Higher%Cortical%Functions%
o General!!Behavior!and!Appearance!
o Stream!of!talk!
o Mood!and!Affective!Responses!
o Content!of!!!Thought!
o Intellectual!Capacity!
o Sensorium!
!
!
% !
% ! TP
% !

TPMD%2017|PEDIATRICS%1%–%Neurological%History%and%Examination%|! P a g e !2!!
!
Sensorium% o Visual! Fields^introduction! of! non^audible! stimulus! from!
o Consciousness! side,!physician!at!the!back!
o Attention!Span! o Funduscopy^attention! to! optic! disc! (color,! size,! margins,!
o Orientation!to!Time,!Place!and!Person! venous!pulsations),!retina!(hemorrhage)!and!macula!!
o Memory,!recent!and!remote! o Diminished! venous! pulsations! is! ! one! of! the! earliest! signs!
o Fund!of!!Information! of!papilledema!
o Insight/!Judgment!and!Planning! %
o Calculation! III%Oculomotor,%IV%Trochlear%and%VI%Abducens!
o Age!appropriate!language!and!psychosocial!skills! o Position!of!the!eyes!at!rest!
! o Pupillary! size,! reactivity,! accomodation! and! convergence;!
Cortical%Mapping% Pupillary!response!maybe!absent!in!infants!<!32!weeks!GA!
o Agnosia^! ! Inability! to! understand! ! the! meaning/symbolic! o Eye! movements! and! ! Dolls’! eye! phenomenon^! conjugate!
significance! ! of! sensory! stimuli! despite! intact! ! sensory! eye! movements! by! 4! months! of! age! and! acoustically!
pathways.! elicited!eye!movements!appear!by!5!months.!
• E.x.!prosopagnosia!–!inability!to!recognize!faces! !
o Apraxia!–!Inability!to!execute!learned!voluntary!acts.! V%Trigeminal%Nerve%
o Aphasia! ^! ! Inability! to! understand! or! express! words! as! o Motor!!Component!
symbols!of!communication! • Action!of!muscles!of!mastication!
• Jaw!movements!and!deviation!
• Jaw!jerk^!exaggerated!in!lesions!above!the!level!of!the!
pons!
o Sensory!Component!
• Corneal!Reflex^!abnormal!if!asymetric!or!absent!
• Facial!sensation!!!(!!3!Divisions)!
!
VII%Facial%Nerve%
o UMN!paresis^!lower!quadrant!of!the!face!
o LMN!paresis^!whole!half!side!of!the!face!
o Weakness!accentuated!by!volitional!movement!
!
%
%
%
! %
%
%
%
%
%
%
%
%
%
%
%
%
%
%
%
! %
Brainstem%Integrity% VIII%Vestibulocochlear%%
o Cranial!nerve!involvement! o Hearing!–!!Ability!to!localize!sound!or!repeat!a!whispered!
o Pattern!of!!Cross!hemiparesis! word!
o Responsible! for! cranial! nerve! reflexes! and! Autonomic!! o Vestibular! function! –! peripheral! sensors! that! detect!
functions!mediated!through!CN!!(!CR/!RR/BP)! motion!and!the!pull!of!gravity!
o Contains!Reticular!Formation!(!tegmental!neurons)! !
! IX%Glossopharyngeal%and%X%Vagus%
TESTING%FOR%CRANIAL%NERVES% o Position! of! uvula! at! rest,! quality! of! voice,! palatal!
II%Optic%Nerve% movements!during!phonation!
o Visual!Acuity!! o Gag!is!absent!in!1/3!of!healthy!individuals!
• Glare!response!from!the!newborn!period.! o Swallowing!and!drooling!
• Blink! reflex! ! appears! between! 3^4! months,! 50%! of! 5! o Note!coordination!of!sucking!and!swallowing!
month!old!infants!and!all!infants!by!1!year.! rd
o Taste! sensation! (posterior! 3 ! of! tongue),! not! worth! the!
• Snellen’s!!and!Jaegers!Charts! effort!
• Visual!Fields! %
• Distraction!Test! XI%Spinal%accessory%
• Confrontation!testing! o Note! movements! of! head! side^to^side! and!
• Perimetry! shrugging! of! shoulders! in! young!
o Funduscopy! children!
o Optic!Nerve! o Strength! of! muscles! and! against! TP
resistance!in!older!children!
TPMD%2017|PEDIATRICS%1%–%Neurological%History%and%Examination%|! P a g e !3!!
!
XII%Hypoglossal% o Hypertonia!
o Position!of!tongue!at!rest! • Notable!resistance!to!passive!movements!on!joints!
o Deviation! during! protrusion! the! tongue! also! deviates! • Varying!degrees!of!posture!(eg,!opisthotonus,!etc)!
towards!the!weak!side! • Fisting:!“Buried”!or!“cortical”!thumbs!
o Fasciculations! should! be! observed! in! a! relaxed! child;! %
cannot!be!determined!with!any!reliability!if!the!youngster! Motor%Examination:%Power!
is!crying! o Various! muscle! groups! should! be! tested! if! child! is! old!
enough!to!cooperate;!young!children!through!observation!
of!their!movements!
• 0!–!No!muscle!contraction!
• 1!–!Flicker!or!trace!of!contraction!
• 2!–!Active!movement,!gravity!eliminated!
• 3!–!Active!movement!against!gravity!
• 4!–!Active!movement!against!gravity!and!resistance!
• 5!–!Normal!power!
o Pronator!sign!–sensitive!test!for!!mild!weakness^!hypotonic!
hand!hyperpronates!
o Muscle! power! in! infants! and! small! children! relies! on! age!
appropriate!gross!and!fine!motor!milestones!
o Symmetries!of!movement!!
o Handedness!is!!established!by!the!age!of!3!years.!
! %
MOTOR%EXAMINATION! MILESTONE%GUIDELINE%
o Observation!of!muscles! Gross%Motor%
o Check!the!tone! Function! Expected%Age% Referral!
o Note!the!Power!by!MMT!or!checking!age!appropriate!gross! Head%control% 2!mos! 4!mos!
and!fine!motor!milestones! Sitting% 6!mos! 8!mos!
o Examine!the!gai! Crawling% 9!mos! 12!mos!
o Note!abnormal!movements! Walking% 12!mos! 18!mos!
o Note!reflexes! %
% Fine%Motor/Social%
Motor%Examination:%Observation! Function! Expected%Age% Referral!
o Child’s!station!(i.e.,!posture!while!standing)!! Smiling% 6!weeks! 3^4!mos!
o Child’s! Gait! ! ! while! ! walking! and! running! should! also! be! Reaching% 4!mos! 5^6!mos!
observed.!E.x.!hemiparetic!gait! Transfer% 6!mos! 8!mos!
o Muscle!Bulk!and!signs!of!Dennervation!
Pincer% 8!mos! >12!mos!
o These! observations! sometimes! defer! examination! of! the!
!
actual!strengths!of!the!muscles!as!normal!findings!suggest!
UMN%and%LMN%Weakness%
muscles!are!strong!and!are!of!normal!tone!
% ! UMN! LMN!
Motor%Examination:%Palpation!
Bulk! Minimal!Atrophy! Profound!Atrophy!
o Muscle%tone%!
Tone! Spastic! Floppy/!Hypotonic!
o Gently!flapping!joints!
DTRs! Hyperreflexia! Hypo/!Areflexic!
o Scarf!sign^!Elbow!does!not!cross!the!midline!
Fasiculations! None! Present!
o Pull^to^sit!/!Traction!response!
Babinski! Present! Absent!
o Vertical!suspension!(holding!onto!the!armpits)!
o Normal!!arm!aduction!,!does!not!slip!through! Sensory% Maybe!present! Maybe!present!
o No!scissoring! Deficit!
o Horizontal! suspension! (prone! position,! holding! on! !
abdomen)^!extensor!predominance!(!age!dependent)! CEREBELLAR%FUNCTIONS!
% o Part!of!the!complex!system!that!modulates!motor!output.!
Muscular%tone%in%infants! o Pathology! :! ! Results! in! ! ipsilateral! incoordination! during!
o First! few! months,! normal! hypertonia! of! the! flexors! of! volitional!movements!
elbows,!hips!and!knees,!decreases!markedly!during!the!3 !
rd o Affected!parts!are!also!hypotonic/!floppy!
month,!cephalad^caudad! o Dysmetria!!observed!when!reaching!for!toys!
o At!the!same!time,!tone!in!neck!and!trunk!increases! o Tandem!gait!is!!performed!well!by!6!years!of!age.!
o Between! 8! and! 12! months,! a! further! decrease! occurs! in! o Ataxia! with! tremor! of! the! extremities! can! be!
flexor! tone! with! an! accompanying! increase! in! extensor! demonstrated! in! the! older! child! on! finger^to^nose! and!
tone! heel^to^shin!testing!
o Passive! tone! best! judged! by! passive! movements! of! the! o Involuntary!movements!can!be!observed!as!child!walks!or!
joints,!while!the!infant!is!awake!and!not!crying!(head!must! executes!some!movements!
be!straight!to!avoid!influence!of!tonic^neck!reflex)! o Accentuation! of! the! tremor! (intention)! as! the! extremity!
% approaches! the! target! is! characteristic! of! cerebellar!
Abnormalities%of%tone! dysfunction!
o Hypotonia! %
• Scarf!sign! %
• Inverted!U^shape!on!horizontal/ventral!suspension! %
• Slipping!through!armpit!on!vertical!suspension! %
• Head!lag!on!pull^to^sit!(no!traction!response)! %
TP
! %
%
TPMD%2017|PEDIATRICS%1%–%Neurological%History%and%Examination%|! P a g e !4!!
!
BASAL%MOTOR%NUCLEI%INVOLVEMENT! Sucking%and%Rooting%reflexes!
o Known!as!the!extrapyramidal!system! o Starts!at!28!weeks!and!persists!!until!3!!months,!replaced!
o Helps! integrate! and! modulate! cortical! ! infromation! that! by!voluntary!sucking/rooting!
control!movement.! o Absent!in!depressed!or!septic!babies!
o Basal!motor!nuclei!project!to!the!ipsilateral!somatomotor! o Persistent!in!CP!or!in!neurodegenerative!disorders!
nuclei!of!the!thalamus.! o Reappears!in!frontal!lobe!dysfunction!
o Disruptions!of!neurochemical!elements!of!the!basal!nuclei! %
result!in!characteristic!contralateral!motor!dysfunction:! DEVELOPMENTAL%REFLEXES!
• Hypokinesia–!rigidity,!bradykinesia! Buttress%response!
• Hyperkinesia^!!tremor,!chorea,!athetosis,!dystonia! o Infant! in! sitting! position:! displace! center! of! gravity! with! a!
• Almost! all! involuntary! movements! will! disappear! gentle! push! on! one! shoulder! ^! infant! extends! the!
during!sleep.! contralateral!arm!and!spreads!the!fingers!
% o Normally!appears!by!5!months!
Reflexes! o Delay! in! its! appearance! and! asymmetries! indicates!
o The!younger,!the!less!informative!the!DTRs! neurologic!dysfunction!
o Reflex! inequalities! are! less! reliable! than! inequalities! of! !
muscle!tone!!in!ascertaining!!UMN!lesions.! Parachute%response!
o Patellar! reflex! is! accompanied! by! adduction! of! the! o Child! suspended! horizontally! (around! the! waist,! face!
opposite! thigh^! known! as! crossed! adductor! reflex^! down),! infant! suddenly! projected! toward! the! floor;!
disappears!by!9!to!12!mos! consequent!extension!of!the!arms!and!spreading!of!fingers!
o Sustained!clonus!suggests!a!pyramidal!tract!lesion! o Emerges!after!6!months,!well^developed!by!8^10!months,!!
% o Abnormal!if!not!expressed!by!1!year!or!if!asymmetric!
Babinski%response! %
o May!be!present!normally!up!to!2!½!year!old!children! SENSORY%TESTING!
o Modifications:! o Crude!testing!of!touch,!pain!and!temperature!
• Oppenheim!(stroking!the!shin)! • Integrity!of!!Spinothalamic!tract!
• Gordon!(squeezing!calf!muscles)! o Finer!sensory!testing:!position,!vibration!sense,!Rhombergs!
• Chaddock!(stroking!lateral!malleolus)! test!
• Gonda!(flicking!one!of!the!toes,!usually!the!little)! • Integrity!of!the!!Posterior!Columns!
• Bing! (poking! a! relatively! sharp! object! on! the! dorsum! o Cortical!sensory!testing!(!parietal!lobe)!
of!the!big!toe)! • Two!point!discrimination,!
% • Stereognosis,!!
PRIMITIVE%REFLEXES! • Graphesthesia!
o Age^dependent! reflexes,! which! disappear! with! CNS! %
maturation! AUTONOMIC%TESTING!
o These! reflexes! do! not! actually! disappear,! they! are! o Salivation,!Lacrimation!
suppressed!as!higher!cortical!centers!become!mature!and! o Sweat! pattern,! skin! temp,! blood! pressure,! heart! rate,!
more!functional! bowel!and!bladder!symptoms!
% o Most!common:!Horner’s!yndrome:!miosis,!anhydrosis!and!
Moro%reflex! enopthalmos!
o First! appears! between! 28^32! weeks! of! gestation,! present! o Commonly!involved!in!Spinal!Cord!lesions!
in!all!newborns! %
o Absent! in! very! small! prematures! and! in! depressed! SIGNS%OF%MENINGEAL%IRRITATION!
newborns!! o Nuchal!rigidity!
o Fades!out!between!3!to!5!months! o Spinal!rigidity!–!more!sensitive!in!under!18!months!of!age!
o Persistence!beyond!6!months!is!abnormal! o Kernig’s!and!Brudzinski’s!signs!
% o Head!tilt!
Tonic%neck%reflex% o Photophobia!
o Infant! supine,! turn! head! to! one! side;! infant! assumes! a! %
“fencing^like”!posture! ! !
st
o Present! at! birth,! but! usually! begin! to! emerge! by! the! 1 !
week,!fully!well!developed!by!1!month!
o Disappears!by!6!months,!persistence!beyond!is!abnormal!
o Obligatory!is!abnormal!irrespective!of!age!
%
Righting%reflex!
o Infant! supine,! turn! head! to! one! side,! infant! rotates! the!
shoulder! to! same! direction,! followed! by! the! trunk,! and!
finally!the!pelvis!
o Obligatory! (shoulder,! trunk! and! pelvis! rotate!
simultaneously,!like!rolling!a!log)!is!always!abnormal!
%
Palmar%and%Plantar%grasps!
o Pressure!on!the!palm!or!sole!
o Plantar!is!weaker!than!palmar!
o Appears! by! 28^32! weeks! gestation,! becomes! weak! and!
wanes!by!5^6!months!(replaced!by!voluntary!activity)!
o Persistence!beyond!6!months!is!abnormal!
o Plantar!reflex!disappears!at!a!later!time!by!9!^10!mos!
TP
%
%
TPMD%2017|PEDIATRICS%1%–%Neurological%History%and%Examination%|! P a g e !5!!
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%
%

TP

TPMD%2017|PEDIATRICS%1%–%Neurological%History%and%Examination%|! P a g e !6!!
!
 BREASTFEEDING,%FOOD%PYRAMID%AND%COMPLEMENTARY%FEEDING%
%
TEN%STEPS%TO%SUCCESSFUL%BREASTFEEDING% EXECUTIVE%ORDER%NO.%51%
1. Have! a! written! breastfeeding! policy! that! is! routinely! (National% Code% of% Marketing% of% Breastmilk% Substitutes,%
communicated!to!all!health!care!stuff! Breastmilk%Supplement%and%Other%Related%Products)%
o SECTION%2.%Aim%of%the%Code!
2. Train!all!health!care!staff!in!skills!necessary!to!implement!
• ‘…provision!of!safe!and!adequate!nutrition!for!infants!
this!policy.!
by! the! protection! and! promotion! of! breast! feeding!
3. Inform! all! pregnant! women! about! the! benefits! and! and! by! ensuring! the! proper! use! of! breastmilk!
management!of!breastfeeding.! substitutes! and! breastmilk! supplements! when! these!
4. Help!mothers!initiate!breastfeeding!within!half!an!hour!of! are!necessary…’!
birth.! o SECTION%3.%Scope%of%the%Code!
5. Show! mothers! how! to! breastfeed,! and! how! to! maintain! • Marketing,! and! practices! related! thereto,! of! the!
lactation! even! if! they! should! be! separated! from! their! following! products:! breastmilk! substitutes,! including!
infants.! infant! formula;! other! milk! products,! foods! and!
6. Give! newborn! infants! no! food! or! drink! other! than! breast! beverages!
milk,!unless!medically!indicated.! o SECTION%6.%The%General%Public%and%Mothers%N!
7. Practice!roomingGin!–!that!is,!allow!mothers!and!infants!to! • No! advertising,! promotion! or! other! marketing!
remain!together!–!24!hours!a!day.! materials!
• Manufacturers!and!distributors!shall!not!be!permitted!
8. Encourage!breastfeeding!on!demand!
to!give,!directly!or!indirectly,!samples!and!supplies!of!
9. Give!no!artificial!teats!or!pacifiers!(also!called!dummies!or! products!
soothers)!to!breastfeeding!infants.!! • There! shall! be! no! pointGofGsale! advertising,! giving! of!
10. Foster!the!establishment!of!breastfeeding!support!groups! samples! or! any! other! promotion! devices! to! induce!
and!refer!mothers!to!them!on!discharge!from!the!hospital! sales!directly!to!the!consumers!at!the!retail!level,!!
or!clinic.! • Manufacturers!and!distributors!shall!not!distribute!to!
% pregnant! women! or! mothers! of! infants! any! gifts! or!
articles! or! utensils! which! may! promote! the! use! of!
PROVISIONS% TO% PROMOTE,% SUPPORT,% AND% PROTECT%
breastmilk!substitutes!or!bottle!feeding!
BREASTFEEDING%
%
REPUBLIC%ACT%7600%%
FEEDING%DURING%THE%FIRST%YEAR%OF%LIFE%!
(The%RoomingNIn%and%BreastNfeeding%Act%of%1992)%
BreastNfeeding%!
o SECTION%2.%%%%Declaration%of%Policy.%
o Feedings! should! be! initiated! soon! after! birth! unless!
• !‘…adopts! roomingGin! as! a! national! policy! to!
medical!conditions!preclude!them!
encourage,! protect! and! support! the! practice! of!
o The! AAP! recommends! exclusive! breastfeeding! for! a!
breastGfeeding.’!
minimum!of!4!months!and!preferably!for!6!months!!
• ‘...placing! the! newborn! in! the! same! room! as! the!
o Mothers!should!be!encouraged!to!nurse!at!each!breast!at!
mother! right! after! delivery! up! to! discharge! to!
each! feeding! starting! with! the! breast! offered! 2nd! at! the!
facilitate! motherGinfant! bonding! and! to! initiate!
last!feeding!
breastfeeding...’!
o It!is!preferable!to!empty!the!1st!breast!before!offering!the!
o SECTION%5.%%%%Normal%Spontaneous%Deliveries%
2nd! in! order! to! allow! complete! emptying! and! therefore!
• Shall!be!put!to!the!breast!of!the!mother!immediately!
better!milk!production.!!
after! birth! and! forthwith! roomedGin! within! 30!
o New! mothers! should! be! instructed! about! infant! hunger!
minutes.!
cues,!correct!nipple!latch,!positioning!of!the!infant!on!the!
→ Well!infants!regardless!of!age!of!gestation;!
breast,!and!feeding!frequency.!A!followGup!appointment!is!
→ Infants!with!low!birth!weights!but!who!can!suck%
recommended!within!24G48!hr!after!hospital!discharge.!!
o SECTION%6.%%%%Deliveries%by%Caesarian.%%
%
• Infants! delivered! by! caesarian! section! shall! be! US:% 5% child% death% %% saved% with% universal% coverage% of% preventive%
roomedGin!and!breastGfed!within!3G4!hours!after!birth! interventions%
o SECTION%8.%%%%Exemptions.% Breastfeeding! ! ! ! 12%!
• Infants! whose! conditions! do! not! permit! roomingGin! Complementary!feeding!! ! ! 6%!
and! breastGfeeding! as! determined! by! the! attending! Zinc! ! ! ! ! 5%!
physician! Vitamin!A! ! ! ! ! 2%!
!
• Infants! whose! mothers! are! either:! a)! seriously! ill;! b)!
Risk%of%Diarrhea%by%Feeding%Method%
taking!medications!contraindicated!to!breastGfeeding;!
Philippines,*Infants*aged*022*months*
c)! violent! psychotics;! or! d)! whose! conditions! do! not! No!breastmilk! ! ! ! 17.3%!
permit! breastGfeeding! and! roomingGin! as! determined! Breastmilk!and!nutritious!supplements!! ! 13.3%!
by!the!attending!physician! Breastmilk!and!nonGnutritious!liquids!! ! 3.2%!
! Breastmilk!only! ! ! ! 1.0%!
! !
! Risk%of%Death%from%Pneumonia%by%Feeding%Method%
! Brazil,*Infants*aged*8*days*to*12*months*
! Formula!only!>!Cow’s!milk!only!>!Breastmilk!
! and!formula!>!Breastmilk!and!cow’s!milk!>! TP
! Breastmilk!only!

TPMD%2017|PEDIATRICS%1%–%Breastfeeding%and%Complementary%Feeding|! P a g e !1!!
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 ABSOLUTE% AND% RELATIVE% CONTRAINDICATIONS% TO% Milk%Leakage%!
BREASTNFEEDING% DUE% TO% MATERNAL% HEALTH% o Milk!is!involuntarily!lost!from!the!breast!!
CONDITIONS%% o either! in! response! to! breastGfeeding! on! the! opposite! side!
MATERNAL% HEALTH% DEGREE%OF%RISK%! or! as! a! reflex! in! response! to! other! stimuli,! such! as! an!
CONDITIONS%! infant’s!cry!
HIV!and!HTLV!infection!! Health! risks! of! not! breastG o Resolves!spontaneously!as!lactation!proceeds.!!
feeding!must!be!weighed!against! %
the! risk! of! transmitting! virus! to! Inadequate%Milk%Intake%!
the!infant!! o Can!surface!after!the!first!48!hours!of!life!
Tuberculosis!infection!! Contraindicated!until!completion! o The! infant! might! cry! or! be! lethargic! and! have! delayed!
of!therapy!! stooling,!decreased!urine!output,!weight!loss!>7%!of!birth!
weight,!hypernatremic!dehydration,!and!increased!hunger!
VaricellaGzoster! Infant! should! not! have! direct!
o May! be! due! to! insufficient! milk! production! or! failure! of!
infection!! contact!to!active!lesions!!
established! breastGfeeding,! but! it! can! also! result! from!
Herpes! simplex! Contraindicated! with! active!
health!conditions!in!the!infant!that!prevent!proper!breast!
infection!! herpetic!lesions!of!the!breast!!
stimulation.!!
CMV!infection!! Transmission! through! human!
o Neonates!must!feed!a!minimum!of!8!times!per!day!
milk!causing! symptomatic! illness!
o Late!preterm!infants!(34G36!wk)!are!at!risk!for!insufficient!
in!term!infants!is!uncommon.!!
milk!syndrome!because!of!poor!suck!and!swallow!patterns!
Hepatitis!B!infection!! No! delay! in! initiation! of! breastG
or!medical!issues.!!
feeding! is! required! if! infants! are!
!
given!vaccines!
Jaundice%!
Hepatitis!C!infection!! Not!contraindicated! o Common! reason! for! hospital! readmission! of! healthy!
Alcohol!intake!! Limit! maternal! alcohol! intake! to! breastfed!infants!
<0.5!g/kg/day!! o related! to! insufficient! fluid! intake,! dehydration! and!
Cigarette!smoking!! Discourage! cigarette! smoking,! is! hypernatremia!
not!a!contraindication! o Breast! milk! jaundice! causes! persistently! high! serum!
Chemotherapy,! Contraindicated!! indirect!bilirubin!in!a!thriving!healthy!baby!
radiopharmaceuticals!! o Declines!in!the!2nd!week!of!life!
% o Infants! with! severe! or! persistent! jaundice! should! be!
Nipple%Pain%! evaluated! for! problems! such! as! galactosemia,!
o One! of! the! most! common! complaints! of! breastfeeding! hypothyroidism,! urinary! tract! infection,! and! hemolysis!
mothers! before! ascribing! the! jaundice! to! breast! milk! that! might!
o Poor! infant! positioning! and! improper! latch! are! the! most! contain! inhibitors! of! glucuronyl! transferase! or! enhanced!
common!reasons!for!nipple!pain!! absorption!of!bilirubin!from!the!gut!
o If! the! problem! persists! and! the! infant! refuses! to! feed,! o Persistently! high! bilirubin! can! require! changing! from!
consider!nipple!candidiasis! breast! milk! to! infant! formula! for! 24G48! hr! and/or!
o In! some! cases,! it! may! be! necessary! to! express! milk! phototherapy!without!cessation!of!breastGfeeding!
manually!until!healing!has!occurred.!! o BreastG! feeding! should! resume! after! the! decline! in! serum!
% bilirubin!
Engorgement%! !!
nd
o Physiologic!fullness!of!the!breast!occurs!in!the!2 !stage!of! Collecting%Breast%Milk%!
lactation! o The! pumping! of! breast! milk! is! a! common! practice! when!
o If! the! breasts! are! firm,! overfilled,! and! painful,! the! cause! the!mother!and!baby!are!separated!
may! be! incomplete! removal! of! milk! due! to! poor! breastG o Good!hand!washing!and!hygiene!should!be!emphasized!
feeding!technique!or!other!reasons!such!as!infant!illness.!! o Electric! breast! pumps! are! more! efficient! and! better!
o Frequent! breastfeeding! or,! in! some! cases,! manual! milk! tolerated! by! mothers! than! mechanical! pumps! or! manual!
expression!before!breastfeeding!may!be!required.!! expression.!!
% o Collection! kits! should! be! rinsed,! cleaned! with! hot! soapy!
Mastitis%! water,!and!air!dried!after!every!use.!!
o 2G3%!of!lactating!women! o Glass! or! plastic! containers! should! be! used! to! collect! the!
o Usually! unilateral,! with! localized! warmth,! tenderness,! milk,!and!milk!should!be!refrigerated!and!then!used!within!
edema,!and!erythema!after!the!2nd!post!delivery!week.! 48!hr.!!
o S.* aureus,! E.* coli,! group! A! streptococcus,! H.* influenzae,! K.* o Expressed!breast!milk!can!be!frozen!and!used!for!up!to!6!
pneumoniae,!and!Bacteroides*spp.!! mo.!!
o Diagnosis!is!confirmed!by!physical!examination.!! o Milk! should! be! thawed! rapidly! by! holding! under! running!
o Oral! antibiotics! and! analgesics,! while! promoting! breastG tepid! water! and! used! completely! within! 24! hours! after!
feeding!or!emptying!of!the!affected!breast,!usually!resolve! thawing!
the!infection! o Milk!should!not!be!microwaved.!!
o If! with! breast! abscess,! requires! intravenous! antibiotics,! %
incision! and! drainage,! along! with! temporary! cessation! of! ! TP
feeding!from!that!breast! %
TPMD%2017|PEDIATRICS%1%–%Breastfeeding%and%Complementary%Feeding|! P a g e !2!!
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ANATOMY%OF%THE%BREAST% o Phase%II%–%Lactogenesis%(initiation%of%milk)%
o Oxytocin!–!contraction!of!muscle!cells! • Stage!I:!starts!12!weeks!before!delivery!
o Prolactin!–!milk!secretion! → Gathering!of!all!substrates!for!milk!production!
o Lactiferous!sinuses!–!site!for!milk!collection! • Stage!II:!2G3!days!postpartum!
→ Milk!secretion!is!copious!
→ Milk!comes!‘in’!!
• Stage!III:!(Galactopoiesis)!
→ Maintenance!of!milk!secretion!
→ Mature!milk!is!established!
→ Intact! hypothalamicGpituitary! axis! regulating!
oxytocin!and!prolactin!levels!is!essential!
%
Influence%of%Local%Factors%Acting%on%the%Breasts%
o It! is! not! just! the! level! of! maternal! hormones,! but! the!
efficiency! of! milk! removal! that! governs! the! volume!
product!in!each!breast!
o A!protein!factor!called!feedback!inhibitor!of!lactation!(FIL)!
is! secreted! with! other! milk! components! into! the! alveolar!
lumen!
o If!milk!is!not!removed,!breasts!remain!full!of!milk!
o FIL,! the! chemical! inhibitor! present,! interacts! with! the!
alveolar! cells! of! the! breast! G>! makes! it! insensitive! to!
prolactin!G>!↓!breast!milk!secretion!
%
HUMAN%MILK%%
!
PHYSIOLOGY%OF%LACTATION% o Preferred!feed!for!all!infants!!!
Reflexes*governing*breast*milk*secretion:* o Sufficient!to!provide!nutrient!needs!until!6!months!of!!life;!
o Prolactin!reflex! should! be! continued! until! two! years! and! beyond!
o LetGdown!or!milk!ejection!reflex!! !supplemented!with!complementary!foods!!!
(Sucking!G>!hypothalamus!G>!prolactin,!oxytocin)! o Serves!as!standard!for!all!breastmilk!substitutes!%%
! PATTERNS%OF%MILK%SUPPLY%%
ENDOCRINE%CONTROL%OF%LACTATION% DAY%OF%LIFE%! MILK%SUPPLY%!
o Prolactin%Reflex%
Day!1!! Some!milk!(~5!mL)!may!be!expressed!!
• Secreted!after!feed!to!produce!next!feed!
Days!2G4!! Lactogenesis,!milk!production!increases!!
• More!prolactin!secreted!at!night!
Day!5!! Milk!present,!fullness,!leaking!felt!!
• Suppresses!ovulation!
Day!6!onward!! Breasts!should!feel!“empty”!after!feeding!!
o Oxytocin%Reflex%
%
• Works!before!or!during!feed!to!make!milk!flow!
Variation%of%Breast%Milk%
• Makes!uterus!contract!! st
o Colostrum!–!1 !3G5!days!
%
o PreGterm!milk!–!7G28!days!
Neonatal%Reflexes%in%Breast%Feeding%
o Mature!milk!–!>30days%
Skill* –* mother* learns* to* position* baby,* baby* learns* to* take*
breast**
g/100ml

g/100ml

g/100ml

o Rooting%reflex%G!when!something!touches!lips,!baby!opens!
Volume

Protein
Kcal/ml
Energy
mmol/
100ml

(ml/d)
Type

mouth,!puts!tongue!down!and!forward!!
CHO

Fat

NA

o Sucking% reflex%G! when! something! touches! palate,! baby!

sucks!! Preterm
D7 461 0.647 2.59 6.23 4.02 2.45
o Swallowing% reflex%G! when! mouth! fills! with! milk,! baby!
D14 413 0.68 2.29 6.21 4.71 2.2
swallows!! D28 452 0.652 1.91 6.39 4.33 1.51
% Drip BM 0.54 1.35 7.1 2.2 0.5
MAIN%PHASES%OF%LACTATION%HORMONAL%CONTROL% Cow 0.67 3.4 4.6 3.9 2.3
o Phase%I%–%Mammogenesis%(mammary%growth)% %
• Profound! during! pregnancy! in! preparation! for! Colostrum%
lactation! o First!postpartum!week’s!mammary!secretion!consisting!of!
→ Placental!lactogen,!estrogen,!progesterone! yellowish!(beta!carotene)!thick!fluid!!
⇒ Ductal!sprouting!(estrogen)! o Has!higher!protein,!lower!fat!and!lactose;!rich!in!Vitamin!A!
⇒ Lobular!formation!(progesterone)! (3x!>!BM),!carotenoid!(10x),!vitamin!E!(3x)!!
→ Prolactin!essential!for!complete!gland!growth! o Protein! content! is! rich! in! IgA! and!
! immunologically! competent!
! mononuclear!cells! TP
! o Contains!antioxidants!%

TPMD%2017|PEDIATRICS%1%–%Breastfeeding%and%Complementary%Feeding|! P a g e !3!!
!
 SELECTED& BENEFICIAL& PROPERTIES& OF& HUMAN& MILK& o Anti2infective*Properties*!
COMPARED&TO&INFANT&FORMULA&& • IgA,! IgM,! IgG:! immunoglobulins! that! guard! the! gut!
Secretory!lgA!! Specific! antigenGtargeted! antiG against!infective!bacteria!!!
infective!action!! • Bifidus! factor:! stimulates! bifidoGbacteria,! which! fight!
Lactoferrin!! Immunomodulation,!iron!chelation,! against!pathogenic!bacteria!!!
antimicrobial! action,! antiadhesive,! • Lactoferrin:!binds!iron!away!from!bacteria!!!
trophic!for!intestinal!growth!! • Macrophages:!phagocytosis!of!infective!bacteria!!!
κGcasein!! Antiadhesive,!bacterial!flora!! • B12!binding!protein:!removes!B12!from!bacteria!
o Maternal*HIV*!!
Oligosaccharides!! Prevention!of!bacterial!attachment!!
• For!HIV!(+)!mothers!to!reduce!the!transmission:!!
Cytokines!! AntiGinflammatory,! epithelial!
• When! replacement! feeding! is! acceptable,! feasible,!
barrier!function!!
affordable,! sustainable! and! safe,! mothers! should! not*
Growth!factors!!
breastfeed! from! birth;! otherwise,! they! should!
Epidermal! growth! Luminal! surveillance,! repair! of!
breastfeed! exclusively! and! make! the! transition! to!
factor!! intestine!!
exclusive! replacement! feeding! as! soon! as! alternative!
Transforming! Promotes! epithelial! cell! growth!
feeding!options!are!feasible.!!
growth!factor!(TGF)!! (TGFGβ)! Suppresses! lymphocyte!
o Breastfeeding*and*premature*infants*!
function!(TGFGβ)!!
• Premature!infants!fed!their!mother’s!milk!were!found!
Nerve! growth! Promotes!neural!growth!! to! have! decreased! incidences! of! sepsis,! meningitis,!
factor!! and!necrotizing!enterocolitis!!
Enzymes!! !
PlateletGactivating! Blocks! action! of! platelet! activating! BENEFITS%OF%BREASTMILK:%SAFE&%
factorG factor!! o Breastmilk! is! sterile! (free! of! contamination),! whereas!
acetylhydrolase!! powdered!infant!formula!may!be!contaminated!!
Glutathione! Prevents!lipid!oxidation!! • Weir! reported! an! outbreak! of!Enterobacter* sakazakii*
peroxidase!! in! USGbased! NICU! due! to! contaminated! infant!
Nucleotides!! Enhance! antibody! responses,! formula!!
bacterial!flora!! • Van!Acker!et!al.!reported!12!infants!developed!NEC;!2!
% died! attributed! to! E.* sakazakii* derived! from!
COMPARISON%OF%MILK%CONTENTS% contaminated!infant!formula!!
o Lactose:!mature!milk!(foremilk!and!hindmilk)!>!colostrum! !
o Protein:!colostrum!>!mature!milk!(foremilk!and!hindmilk)! BENEFITS%OF%BREASTFEEDING:%MOTHERS&%
o Fat:!hindmilk!>!colostrum!>!foremilk!! o Prevents*obesity*!
% • Early!return!to!preGpregnancy!weight!!!
BENEFITS%OF%BREASTMILK%% • Breastfeeding!mothers!lose!500!kcal/day!!
o Enhances!cognitive!development!!! o Breast*and*Ovarian*Cancer*!!
o Protective:!both!for!baby!and!mother!!! • Breastfeeding!has!consistent!protective!effect!against!
o Cheap!and!free:!benefits!the!economy!!! breast!cancer!!!
o Safe!!! • Breastfeeding!decreases!risk!of!ovarian!cancer!!
! !
BENEFITS%OF%BREASTMILK:%INFANT&%% WHAT%ARE%THE%BENEFITS%OF%BREASTFEEDING?%%
o Enhances*cognitive*development*!! o Osmolality&and&Renal&Solute&Load&%
• Docosohexanoic!acid!(DHA)!! • Human!milk:!!
→ Fatty!acid!derived!from!linolenic!acid!! → Low,! less! than! 300! mosmolar,! gut! can! easily!
→ Only!found!in!breastmilk!in!consistent!level!! handle!!
→ Important! substance! for! the! myelin! sheath! of! → Creates!renal!solute!load!of!13!mosmol/100kcal!!
nerve!fibers!! • Cow’s!milk:!!
→ Vital!nutrient!for!the!growth!and!development!of! → Higher!osmolality!!
brain!tissue!and!good!vision!! → Renal!solute!load!of!46!mosmol/100kcal!!
→ Researches!showed!that!it!is!this!substance!that! → Skim! milk! with! milk! solids! added:! renal! solute!
enhances!cognitive!development!! load!of!86!mosmol/100kcal!!
• Lactose!! → Infant!formulas:!18G25!mosmol/100kcal!!
→ Predominant!carbohydrate!of!breastmilk!! • Fat:**Goat*>*human*=*cow*
→ Disaccharide!consisting!of!glucose!and!galactose!! • Protein:*Cow*>*goat*>*human*
→ Galactose!combines!with!lipid!to!form!galactoseG • Lactose:*Human*>*cow*>*goat*!
lipid,! a! valuable! nutrient! for! brain! tissue! !
development!! !
• ‘Skin!to!skin’!contact!and!‘face!to!face’!position!! !
→ Enhances! the! cognitive! and! educational! !
development!of!children!as!each!feeding!time!is! ! TP
a!learning!opportunity!for!mother!and!child!! !

TPMD%2017|PEDIATRICS%1%–%Breastfeeding%and%Complementary%Feeding|! P a g e !4!!
!
o Proteins&% COMPLEMENTARY%FEEDING%GUIDELINES%(WHO/PAHO,%2002)%%
• Whey!or!soluble!proteins!! “It* is* the* right* of* every* child* to* have* access* to* safe* and*
→ Form!very!light!curds!and!are!easy!to!digest!! nutritious* food* which* are* both* necessary* to* achieve* such*
→ Whey! proteins! in! human! milk! high! in! antiG highest*state*of*well2being.”**
infective!proteins!(mainly!IgA)!! %
→ These! antibodies! coat! the! surface! of! the! small! Recommendations% to% ensure% optimal% growth% and%
intestine,! blocking! binding! sites! from! bacteria! development%of%children%%
and!allergens!! o To!breastfeed!within!one!hour!after!birth!!!
• Casein!! o To!breastfeed!exclusively!for!six!months!!!
→ Forms! very! thick! curds! and! is! very! difficult! to! o To! start! complementary! feeding! at! six! months! of! age!
digest!! !while! continuing! breastfeeding! until! two! years! and!
o Carbohydrates& beyond!!!
• Lactose!(milk!sugar)!! %
→ Predominant!CHO:!disaccharide!(glu/gal)!! Complementary%Feeding%%
→ Provides! ready! source! of! galactose,! which! is! o Process! of! starting! food! at! 6! months! when! breast! milk!
essential!to!CNS!development!! alone!is!no!longer!sufficient!to!meet!the!nutritional!needs!
of! a! growing! infant,! hence! other! food! and! liquids! are!
→ Improves!absorption!of!calcium!and!phosphorus!
needed,!along!with!breast!milk!!
which! is! critical! in! the! prevention! of! rickets!
o Target! age! range:! 6! to! 24! months! of! age! while!
among!babies!
breastfeeding! is! advised! to! be! continued! until! two! years!
→ Enhances!growth!of!L.!bifidus*as!gut!flora!!
and!beyond!
o Lipids&%
o Importance!of!such!feeding!practice!!
• Provide!50%!of!calorie!content,!thus,!major!source!of!
• To!fill!in!the!nutrient!gap!of!breast!milk!at!this!age!!
calories!!!
• To! train! the! infant! in! appropriate! feeding! skills!
• Composition!!!
necessary!for!healthy!eating!habits!in!adult!life!!
→ Palmitic!acid,!oleic!acid!!
o 6G15! months:! “critical! learning! period”! for! feeding! –!
→ Phospholipids!!
chewing!and!swallowing!coordination!is!being!developed!!!
→ Essential!fatty!acids:!linoleic!and!linolenic!acids!!
o Failure! of! infants! to! go! through! this! process! G>! feeding!
→ PUFA:!DHA,!arachidonic!acid!!
problems!!!
→ Cholesterol!!
• Dependence!on!milk!as!source!nutrients!!
→ BileGsalt!stimulated!lipase!!
• Picky!eaters/neophobic!!
• Differences*in*the*fats*of*different*milks*!
• Malnutrition!(obesity/wasting!anemia)!!
→ Human!–!with!lipase!and!essential!fatty!acids!!
%
• Differences*in*Vitamins:!Vit!A,!C,!B!vitamins!!
SIGNALS% THAT% INDICATE% READINESS% OF% THE% INFANT% FOR%
→ Human!>!cow’s!! COMPLEMENTARY%FEEDING:%%
• Differences*in*Iron:!! o Birth!weight!has!doubled!!!
→ Human!–!50%!absorbed;!cow’s!–!10%!! o Extrusion!reflex!has!completely!disappeared!!!
o Calcium&& o Has!good!head!and!neck!control!!!
• Breast!milk!contains!only!about!a!third!of!the!calcium! o Sits!up!with!support!!!
as!compared!to!cow’s!milk!!! o Opens! mouth! if! wants! food;! turns! head! away! when! !not!
• Absorption!of!calcium!from!breast!milk!is!much!better! interested!anymore!!!
due!to!low!level!of!phosphates!!and!fats! o Has!good!chewing!and!swallowing!coordination!!!
• High! levels! of! lactose! also! promote! absorption! of! o Consumes!about!32oz!of!milk!and!wants!more!!!
calcium!!! o Breastfeeds!>10x!and!wants!more!%
! !
! FEATURES%OF%COMPLEMENTARY%FOODS%(PAST)%%%
! o Properly%fed%%
! • Meal! frequency,! feeding! methods! should! be! suitable!
! for!age!(with!fingers,!spoon!and!fork,!cups!and!bowls;!
! guided! or! selfG! feeding),! food! consistency! (pureed,!
! soft,!lumpy,!table!food)!!
! o Adequate%
! • Should! provide! sufficient! energy,! protein! and!
! micronutrients!!
! o Safe%%
! • Hygienically!stored!and!prepared!and!fed!using!clean!
!
utensils,!not*bottles!nor!teat!!
!
o Timely%%
!
• Should! be! introduced! by! six!
!
months!!
! TP
%
!

TPMD%2017|PEDIATRICS%1%–%Breastfeeding%and%Complementary%Feeding|! P a g e !5!!
!
GUIDING%PRINCIPLES%FOR%COMPLEMENTARY%FEEDING%OF%THE%% 7. Wrists!!!
BREASTFED%CHILD%(WHO%AND%PAHO,%2002)%% 8. Rinse!and!wipe!dry!!!
% o Utilize! only! safe! water! and! raw! materials! for! cooking! and!
Guideline%1:%Duration&of&exclusive&breastfeeding&and&age&of&% drinking!purposes!!
introduction&of&complementary&foods&% o Cook! foods! well,! store! them! with! covers! and! at! safe!
o Practice!exclusive!breastfeeding!from!birth!to!6!months!of! temperature!and!served!immediately!after!preparation!!
age,! and! introduce! complementary! foods! at! 6! months! of! o Clean! all! utensils! properly! before! using! them! as! food!
age!(180!days)!while!continuing!to!breastfeed!! containers!and!for!serving!foods!!
o Scientific%Rationale%% o Use! clean! cups! and! bowls,! not! feeding! bottles! which! are!
• Exclusive!breastfeeding!for!6!months!confers!benefits! difficult!to!keep!clean,!for!feeding!children!!
both!for!infants!and!mothers!! o Scientific%Rationale%%
! • Bacterial! contamination! of! foods! is! a! major! cause! of!
Guideline%2:%Maintenance&of&breastfeeding&% gastrointestinal!infections!!!
o Continue! frequent,! on! demand! breastfeeding! until! two! • Coincides! with! the! increased! intake! of!
years!of!age!and!beyond!! complementary!foods!!!
o Scientific%Rationale%% !
• Breast! milk! contains! very! important! nutrients! Guideline%5:%Amount&of&CF&given&%%
beneficial!even!to!infants!well!beyond!the!first!year!of! o Start! at! 6! months! of! age! with! small! amounts! of! food! and!
life!!! increase! the! quantity! as! the! child! grows! older! while!
• When!consumed!in!an!‘average’!amount!(710G803!ml! continuing!to!breastfeed!!!
(476G538! kcal)! /day)! by! a! 12G23! month! old! infant! o Energy!needs!from!CF!for!infants!with!‘average’!(710G!803!
provides!about!35G40%!of!his!nutritional!needs!!! ml! (476G538! kcal)! /day)! breast! milk! intake!in! developing!
• Contains!high!fat!content!which!makes!it!a!very!good! countries!are!as!follows:!!!
source!of!energy!and!essential!fatty!acids!! o Energy*needs*from*CF*with*Average*BM*intake*!
!
Guideline%3:%Responsive&feeding&%% Age!(mos)!! TER!! CalCF! CalBM!
o Practice! responsive! feeding! applying! the! principles! of! (kcal/day)!! (kcal/day)!!
psychosocial!care!specifically:!(Pelto*et*al.,*2002)*! 6G8!! 615!(720)!! 200!! 415!(520)!!
o Feed! infants! directly! and! assist! older! children! when! they! 9G11!! 686!(720)!! 300!! 386!(420)!!
feed! themselves,! being! sensitive! to! their! hunger! and! 12G23!! 894!(1070)!! 550!! 344!(520)!!
satiety!cues!! !!
o Feed!slowly!and!patiently,!and!encourage!children!to!eat,! !
but!do!not!force,!harass!and!get!mad!at!them!! o Scientific%Rationale%%
o If! children! refuse! many! foods,! experiment! with! different! • Exclusive! breastfeeding! is! sufficient! only! to! sustain!
food! combinations! ,tastes,! textures! and! methods! of! the!needs!of!a!growing!infant!until!6!months!!!
encouragement!! • Beyond! 6! months,! there! is! a! need! to! introduce!
o Minimize! distractions! during! meals! if! the! child! loses! complementary! foods! to! maintain! the! healthy!
interest!easily!! nutritional!state!of!infants!and!young!children!!!
o Remember!that!feeding!times!are!periods!of!learning!and! !
love! –! talk! to! children! during! feeding,! with! eye! to! eye! Guideline%6:%Food&consistency&%%
contact!! o Progressively!increase!the!consistency!and!variety!of!food!
o Scientific%Rationale%% as!infant!gets!older,!adapting!to!the!infant’s!requirements!
• Successful! introduction! of! complementary! good! and!abilities!!!
depends!not!only!on!the!kind!of!food!being!given!but! o Infants!can!eat!!!
more! importantly! on! the! manner,! time! and! the! • Pureed!mashed!and!semiGsolid!foods:!6!months!
person!who!feeds!the!child!!! • “Finger! foods”! (snacks! that! can! be! eaten! by! children!
• Active! participation! of! a! caregiver! in! feeding! a! child! alone):!8!months!!
has!been!hypothesized!to!improve!the!dietary!intake!! • Lumpy!foods:!10!months!!
! • Table!foods:!12!months!!
%Guideline%4:%Preparation&and&storage&of&CF&%% • Avoid! foods! such! as! nuts,! grapes! and! carrots! that!
o Practice!good!hygiene!and!proper!food!handling!! could!be!lodged!in!the!trachea!may!cause!choking!and!
o Caregivers! and! food! handlers! should! wash! thoroughly! should!be!avoided!!
their!hands!before!preparing!food!! o Scientific%Rationale%%
o Children!should!was!thoroughly!their!hands!before!eating;! • Consistency! of! food! that! could! be! initiated! is!
observe!the!’10!steps!to!success!in!handwashing’!! dependent! on! the! neuroGmuscular! development! of!
o Proper!HandGwashing!! the!infant!!
1. Palm!to!palm!!! !
2. Between!fingers!!! !
3. Back!of!hands!!! !
4. Base!of!thumbs!!! !
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5. Back!of!fingers!!! !
6. Fingernails!!!
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Guideline%7:%Feeding&frequency&%
o Increase! the! number! of! times! that! the! child! is! fed! CF! as!
he/she!gets!older!!
o Appropriate! number! of! feedings! is! dependent! on! the!
energy! density! of! the! food! as! well! as! the! amount!
consumed!at!each!feeding!!
o Scientific%Rationale%%
• Meal! frequency! was! calculated! based! on! the! ageG!
specific!energy!daily!requirements!minus!the!average!
energy! intake! from! breast! milk! by! children! in!
developing!countries!!
→ Infants!with!low!intake!of!breast!milk!(frequency!
of! less! than! 8! times! a! day)! would! require! more!
CF!feedings,!3x!for!6G8!months!and!4x!thereafter!!
• Food! given! more! frequently! than! recommended! is!
not! advisable! as! this! could! cause! displacement! of!
breast! milk,! reduction! of! breast! milk! secretion! with!
subsequent!weaning!!
• Snacks!may!be!given!2x/day!
! •
Age (months) Feeding frequency/day ! !multivitaminGmineral! preparation! ensures! the! wellG
6-24 2-3 ! being!of!both!mother!and!infant!!!
9-11 3-4 ! !
12-24 3-4 ! Guideline%10:%Feeding&During&Illness&%
! o Increase! fluid! intake,! breastfeed! more! often! and!
Guideline%8:%Nutrient&content&%
o Give!meat,!poultry,!fish!or!eggs!as!often!as!possible!!
o Give! children! at! this! age! who! are! on! vegetarian! diets!
supplements! or! fortified! foods! to! meet! their! nutrient!
needs!!
o Supply!vitaminGA!rich!fruits!and!vegetables!daily!!
o Avoid! low! nutrient! value! drinks! such! as! tea,! coffee! and!
sugary!drinks!such!as!soda!!
o Limit! the! amount! of! juice! to! 8oz! a! day! so! as! to! avoid!
displacing!more!nutrients!!
o Scientific%Rationale%
• Micronutrient!content!!
→ Nutrient!needs!during!first!two!years!after!birth!
are!very!high!due!to!the!rapid!rate!of!growth!and!
development!during!this!age!!
→ Several! nutrients! are! found! to! be! low! in! breast!
milk! which! needs! to! be! filled! up! by!
complementary!food!!
→ Iron,! zinc,! phosphorus,! magnesium,! sodium!
calcim!
• Fat!content!!
→ Provides!EFA!namely!linolenic!(precursor!of!DHA)!
and!linoleic!acid!!
→ Forms!part!of!myelin!sheath!!
→ Facilitates! absorption! of! fat! soluble! vitamins:!
Vitamins!ADEK!!
→ Source!of!concentrated!energy!(9kcal/gm)!
→ Precursors!for!some!important!hormones!!
• Beverages!with!low!nutrient!values!o!Coffee,!tea,!soft!
drinks!and!sugary!!
→ Commercial! drinks! are! not! recommended! for!
children!!
→ These!drinks!satisfy!the!appetite!of!children!but!
are!devoid!of!proper!nutrients!for!proper!growth!!
→ Intake! of! fruit! juice! should! be! limited! to! only!
240ml!per!day!!
Guideline% 9:% Use& of& vitaminJmineral& supplements& or& fortified&
products&for&infant&and&mother&%
o Mothers! may! also! need! vitaminGmineral! supplements! or!
fortified!products,!both!for!their!own!health!and!to!ensure!
normal! concentration! nutrients! specifically! vitamins! in!
their!breast!milk!!
o Scientific%Rationale%%
• Complementary!foods!that!are!not!fortified!especially!
if! plantGbased,! lack! the! key! nutrients! (iron,! zinc,! and!
calcium)! necessary! to! sustain! the! needs! of! growing!
infants!from!6G24!months)!!!
• To! address! such! dietary! dilemma! in! this! age!
population:!!!
→ Food!fortification!!
→ VitaminGmineral!supplementation!!
• Maternal! manlnutrition! can! affect! the! concentration!
!of!vitamins!in!breast!milk!!!
• Improvement! of! the! nutritional! status! of! lactating!
!mother!ensures!highest!quality!of!breast!milk!!!
Supplementation! with! fortified! foods! or! drinks! or! of!
encourage!the!child!to!eat!soft,!varied,!appetizing,!favorite!
foods!during!illness!!!
o After! illness,! give! food! more! often! than! the! usual! and!
encourage!the!child!to!eat!more!!!
o Scientific%Rationale%!!
• During! illness,! infants! are! usually! anorexic,! intake! is!
very!much!reduced!than!their!requirements!of!rage!!!
• Breastfeeding! then! must! be! given! more! frequently!
since! infants! prefer! breast! milk! over! other! foods!
when!sick!!!
• CF!must!be!given!in!small!but!more!frequent!servings!
to!compensate!for!the!decreased!CF!during!illness!
!
Steps%on%the%Introduction%of%Complementary%Foods%(American%
Academy%of%Pediatrics,%2009)%!!
o Introduce!one!ingredient!new!food!at!a!time!and!observe!
for!3G5!days!for!possible!allergic!reactions!!!
o Introduce!new!foods!after!3G5!days!If!no!food!intolerance!
observed!previously!!!
o Choose! first! foods! that! provide! key! nutrients! and! help!
energy!needs!!!
o Start! with! ironGfortified! cereals! and! pureed! meats! as! first!
foods!!!
• These! foods! contain! a! good! amount! of! protein,! iron!
and!zinc,!the!nutrients!found!globally!deficient!among!
infants!and!children!!
o Introduce! a! variety! of! foods! (table! foods)! by! the! end! of!
first!year.!!!
o Withhold! cow! milk! and! other! milks! not! specifically!
formulated!for!infants!during!the!first!year!of!life!!!
o Do!not!introduce!fruit!juices!during!the!first!six!months!of!
life,! thereafter,! offer! only! fresh! fruit! juice! limiting! intake!
to:!!!
• 4G6!oz!daily,!1G6!years!old!!
• 8G12!oz!daily,!8G12!years!old!!
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TPMD%2017|PEDIATRICS%1%–%Breastfeeding%and%Complementary%Feeding|! P a g e !8!!
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 PREVENTIVE%PEDIATRIC%HEALTH%CARE%
%
PREVENTIVE%PEDIATRIC%HEALTH%CARE%% Tertiary%Prevention%%
o At!the!core!of!the!field!of!pediatrics!!! o Directed!at!ameliorating!or!halting!disabilities!!
o Consists!of!efforts!by!physicians!to!avoid!rather!than!!cure! o Examples:!
disease! and! disability! in! children! through! health! • Physical!therapy!for!a!child!with!cerebral!palsy!!
!promotion!and!prevention!activities!!! • Chest!physiotherapy!in!a!child!with!cystic!fibrosis!!
o Evolved!into!regularly;scheduled!visits!(well;child!!care)!to! *
assure! adequate! nutrition,! detect! and! immunize! against! HEALTH%PROMOTION%AND%ANTICIPATORY%GUIDANCE%%
infectious! diseases,! and! observe! the! child’s! development,! o Shift!the!focus!to!wellness!and!to!strengths!of!the!family!!!
among!many!others!!! o An! opportunity! to! help! the! family! address! relationship!
! issues,! to! broach! important! safety! topics,! to! access!
TASKS%OF%PREVENTIVE%PEDIATRIC%HEALTH%CARE%%% community!services,!etc.!!
o Disease!detection!!! !
o Disease!prevention!!! PRENATAL%VISIT,%EDUCATION%AND%COUNSELING%%%
o Health!promotion!!! A. Breastfeeding!!!
o Anticipatory!guidance!! B. Newborn!care!and!procedures!at!birth!!!
! o Rooming!in!!
DISEASE%DETECTION%%% o Newborn!screening!!
o Accomplished!by!both!screening!and!surveillance!! o Hearing!screening!!
o Examples:*! o Immunization!with!Hepatitis!B!and!BCG!!!
• Anemia!! C. Anticipatory! guidance! to! prevent! injury! and! child!
→ Surveillance! is! accomplished! through! taking! a! maltreatment!
dietary!Hx!and!seeking!signs!of!anemia!on!PE!! o Information!regarding!parents’!education,!profession,!
→ Screening!is!by!hematocrit!or!hemoglobin!tests!! attitude! towards! pregnancy,! planned! disciplinary/!
• Development!! child;rearing! approach,! financial! security,! family!
→ Surveillance!relies!on!the!observation!of!parents! support!system!!!
and!watchful!eyes!of!health!providers!! o Injury! prevention! and! potential! exposure! to!
→ Screening! uses! a! structured! developmental! environmental!toxicants!like!lead!!!
screening!tool!! o Deleterious! effects! of! smoking! and! alcohol! intake! on!
! the!fetus!!!
DISEASE%PREVENTION%% D. Tetanus!toxoid!immunization!for!the!mother!!
o Includes! primary,! secondary,! and! tertiary! levels! of! o Must!be!started!or!continued!during!pregnancy!!!
prevention!!! o Schedule:!!
o Can! occur! at! the! level! of! the! individual,! the! family! or! the! 1. TT1!at!1st!contact!!
community!!! 2. TT2!at!least!4!weeks!after!TT1!!
o Benefit!comes!from!risk!reduction!!! 3. TT3!at!least!6!weeks!after!TT2!!
! 4. TT4!at!least!1!year!after!!
LEVELS%OF%PREVENTION%% 5. TT5!at!least!1!year!after!!!
Primary%Prevention%%% E. Maternal!nutrition!to!include!folic!acid!supplementation!!!
o Measures!directed!at!avoiding!disorders!before!they!begin!! !
o Emphasis!on!those!who!are!at!increased!risk!to!develop!a! RECOMMENDATIONS%FOR%PREVENTIVE%HEALTH%CARE!
condition!or!a!disease!! At#birth:#!
o Examples:!! o Colostrum%;!the!perfect!first!food!for!the!newborn!!
• Chlorination!and!fluoridation!of!water!! o LatchingNon% and% breastfeeding% ;! must! be! initiated! during!
• Tetanus!immunization!! the!first!30!minutes!to!one!hour!after!delivery!!
• Counseling! parents! about! keeping! poisons! and! drugs! out! #
of!reach!!! Minimum#criteria#for#discharging#newborns#before#48#hours#!
% 1. Uncomplicated! ante;,! intra;,! and! post;partum! courses! for!
Secondary%Prevention%% both!mother!and!newborn!!!
o Involves!measures!in!which!a!condition!or!its!precursor!is! 2. VSD,!singleton,!completed!37!weeks,!AGA!!!
identified! early! and! effective! treatment! instituted! for! 3. Normal!and!single!VS!during!the!preceding!12!hours!!!
remediation! of! the! condition! before! progression! or! for! 4. Has!urinated!and!passed!at!least!1!stool!!!
elimination!of!the!precursor!% 5. Has! documented! proper! latch,! milk! transfer,! !swallowing,!
o Examples:!! infant! satiety! and! absence! of! nipple! discomfort.!If! not!
• Screening!programs!for!adolescent!scoliosis!! breastfed,! has! tolerated! at! least! 2! feedings! with!
• Screening!for!lead!levels!! documented! coordinated! sucking,! swallowing,!
and!breathing!while!feeding!
• Treatment! of! streptococcal! sore! throat! with!
6. Normal!physical!examination!!!
appropriate!antibiotics!!
7. No! evidence! of! significant! TP
! st
jaundice!in!the!1 !24!HOL!!!
!
TPMD%2017|PEDIATRICS%1%–%Preventive%Pediatrics%|! P a g e !1!!
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8. Educability!and!ability!of!parents!to!care!for!their!child!!! 2. Infants!with!metabolic!disorders!!!
9. Must!follow;up!within!the!next!48!hours!!! 3. Family!history!of!retinoblastoma!!!
# 4. Family!history!of!congenital!cataract!!!
Complete#History#and#Physical#Exam#* 5. History! of! maternal! infection! (rubella)! or!
o Every! infant! must! be! totally! appraised! at! birth,! daily! until! !genitourinary!infections!(STD)!!!
discharge!and!at!each!child!visit!! 6. History!of!squinting!!!
# 7. History!of!visual!difficulties!!!
Developmental#Surveillance## 8. Vitamin!A!deficiency!or!history!of!night!!blindness!!!
o Should! be! done! at! each! child! visit! from! birth! to! 19! years! 9. Children! with! impairments! (CP,! Down’s! !syndrome,!
old!! hearing!impairment,!etc.)!!!
#
!! ! !
Measurement#of#Weight#and#Length/Height#!
Age%! Things%to%check%! Refer%!
o Should!be!done!at!each!child!visit!from!birth!onwards!! Equal/central! corneal! Non;central! unequal!
# 6!mos!! reflex! Fixes! and! corneal! reflex!Blank!
Measurement#of#Head#Circumference#! follows!! stare!!
Non;central! unequal!
o Should!be!done!at!each!child!visit!from!birth!to!3!years!old!!
Equal/central! corneal! corneal! reflex!LEA! at!
# 3!years!! reflex!LEA! at! least! least! 2;/40! (0.5)! or! >1!
Measurement#of#BP#! 20/40!(0.5)!! line! difference!
o Must!be!routinely!done!starting!age!3!years!!! between!eyes!!
Non;central! unequal!
o Must!be!performed!also!in:!!! Equal/central! corneal!
corneal! reflex!LEA! at!
reflex!LEA! at! least!
• All!ill!patients!! 6!years!! least! 20/32! or! >1! line!
20/32! (0.63)! or!
• Patients!at!risk!regardless!of!age,!with!history!and!PE! difference! between!
Snellen!20/40!!
eyes!or!Snellen!<20/40!!
suggestive!of!possible!renal!and!vascular!causes!of!!
The*ff.*are*to*be*checked*in*detail*during*specified*ages:**
HPN!!
!
#
Immunization#!
Screening#for#Atopy#!
o Every! visit! should! be! an! opportunity! to! update! and!
o Any!child!with!a!family!history!of!atopy!who!presents!with!
complete!a!child’s!immunization!!
recurrent/persistent! symptoms! of! 1! or! more! of! the!
!
following!should!be!investigated!!
Iron#Supplementation#!
• GI!symptoms!–!diarrhea,!colic,!vomiting,!bleeding!!!
• Skin!rash!!! Targets%! Preparation%! Dose%!
• Nasal! symptoms! –! rhinorrhea,! stuffiness,! sneezing,! 0.3!mL!OD!from!2;6!
Drops:! 15mg!
!itchiness!!! mos! when!
LBW%! elemental!
• Coughing!with!or!without!wheezing!!! complementary!
iron/0.6!mL!!
! foods!are!given!!
GENERAL%PROCEDURES%! Infants%! Drops:! 15mg!
0.6! ml! OD! for! 3!
Screening#for#Inborn#Errors#of#Metabolism#! (6;11! elemental!
months!!
o Should!be!performed!on!all!newborns!after!24!HOL!but!not! mos)!! iron/0.6!mL!!
later!than!3!days!after!birth!!! 1! tsp! OD! x! 3! mos!
o A! newborn! that! must! be! placed! in! ICU! may! be! exempted! Syrup:! 30mg! OR! 30! mg! weekly! x!
from!the!3;day!requirement!but!must!be!tested!by!7!days! Children%!
elemental! iron/5! 6! mos! w/!
of!age!!! (1;5!y/o)!!
mL!! supervised!
! administration!!
Screening#for#Hearing#Impairment#!! Tablet:! 60mg!
o Recommended!for!all!newborns,!whether!high;risk!or!non; Girls%!
elemental! iron! One!tablet!OD!!
high!risk,!no!later!than!one!month!of!age!!! (10;19!
w/400! mcg! folic! !!
o Those! who! do! not! pass! screening! should! have! !complete! y/o)!!
acid!!
audiological!evaluation!at!no!later!than!3!months!of!age!!! #
# Vitamin#A#Supplementaiton#
Screening#for#Visual#Defects#!!
!
o Should! be! done! at! least! once! for! all! children! at! preferred! Targets%! Preparation%!
Dose%!
ages!(at!birth,!6!months,!3!years,!5!years)!!!
o Screening!at!birth!includes:!!! 1! dose! only! (usually!
• Checking!for!steady!eyes!! Infants%!
100,000!IU!! given! at! 9! mos! during!
White!lustrous!conjunctiva!! (6;11!mos)!!
• measles!immunization)!!
• Pupillary!reflex!!
• Clear!cornea!! Children%!
1!capsule!q!6!mos!!
• Non;droopy!eyelids!! (12;71! 200,000!IU!!
!!
• Red!orange!reflex!!! mos)!!
o Comprehensive!ophthalmologic!exam!for!the!ff:!! # TP
1. Premature!(<32!weeks)!and/or!LBW!(<1500kg)!!! #

TPMD%2017|PEDIATRICS%1%–%Preventive%Pediatrics%|! P a g e !2!!
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Screening#for#Tuberculosis#(Mantoux#Test)#! Anticipatory%Guidance%!
o Recommended! at! least! once! for! asymptomatic! children! 1. First#Dental#Visit#%
between!1!and!14!years!old!!! o The! first! dental! visit! is! recommended! at! the! time! of!
o Recommended!anytime!for!symptomatic!children!!! eruption!of!first!tooth!and!no!later!than!12!months!of!
o Uses!5!TTU!PPD!and!read!at!48;72!hours!!! age!!
o Regardless! of! BCG! status,! an! induration! of! ≥5mm! is! Dental!Care!!
!considered!positive!in!the!presence!of!any!or!all!of!the!ff:!!!
• Hx!of!close!contact!with!a!known!or!suspected!case!of! Fluoride%
Age% Frequency/%
TB!! concentration% Amount%
Group% day%
• Clinical!findings!suggestive!of!TB!! (PPM)%
• Chest!X;ray!suggestive!of!TB!!! Tooth!cleaning!
6!mos!
with!small!smear!
• Immunocompromised!condition!! –!2! Twice!
of!regular!
o In! the! absence! of! the! above,! an! induration! of! ≥10mm! is! years!
toothpaste!
considered!positive!! 2!–!6! Half!a!
# Twice!
years! pea!
Deworming#! 6!years!
o For!all!children!aged!12!months!to!14!years!!! and! Pea!size!
o Schedule:!Single!dose!every!6!months!!! above!
o Dose:!! %
• Albendazole%!! Dental!Care:!other!anticipatory!measures!!
→ 12;24!mos!–!200!mg;!≥!24!mos!–!400!mg!! o Guidance!on!oral!hygiene!and!infant!diet!!!
• Mebendazole% o Cleansing!the!infant’s!teeth!as!they!erupt!either!with!
→ %≥!12!mos!–!500!mg!!! !washcloth! or! soft! brush! will! help! reduce! bacterial!
o Must! not! be! done! in! children! with:! Severe! malnutrition,! !colonization!!!
high!fever,!profuse!diarrhea!or!abdominal!pain!!! o Use! of! dental! floss! is! important! to! reduce!
! !interproximal!caries!!!
PROCEDURES%FOR%PATIENTS%AT%RISK%! 2. Nutrition#Counseling#%
Complete#Blood#Count#! o Counseling! regarding! breastfeeding! started! during!
o PSHBT:%should!be!done!at!least!once!between!6;24!mos;!2; !the! prenatal! period! must! be! continued! during! well;!
6!years;!10;19!years!!! !child!visits!!!
o SAMPI:!should!be!done!at!each!stage!of!adolescence!!! o Giving! of! foods! that! are! too! sweet! (sweetened!
o Those!at!risk:!!! !beverages,! candies),! too! salty! (chips,! curls),! and! too!
• Poor!nutritional!history! !oily!(gravies,!dressings)!should!be!avoided!!!
• Active! menstruating! females! adolescents! and! fad! o Media! food! advertising! may! influence! children’s!
dieters! !choices!toward!higher;fat!or!higher;energy!foods!!!
# 3. Physical#Activity#%
Urinalysis#! o A! physically! active! lifestyle! will! be! carried! into!
o Should! be! done! for! all! patients! with! signs! and! symptoms! !adulthood! and! reduce! health! problems! related! to!
suggestive!of!a!possible!renal!disease!regardless!of!age!!! !inactivity!!!
o SAMPI! recommends! screening! urinalysis! on! first! o Age;appropriate! physical! activities! for! 60! minutes!
adolescent!visit!!! !daily!or!on!most!days!of!the!week!!!
! o Discourage! children! from! prolonged! periods! of!
WorkOup#for#Sexually#Active#Adolescents#!! !sedentary!activity!for!periods!>2hrs/day!!!
o For!sexually!active!females!! 4. Injury#and#Poisoning#Prevention#!
• Annual!vaginal!wet!mount!and!PAP!smear!!
The!following!are!policy!statements!of!the!PPS,!Inc.!!
o For!sexually!active!males!!
o Child!safety!in!private!motor!vehicles!!!
• Annual!serological!test!for!syphilis!!
o Child!safety!in!public!motor!vehicles!!!
o For! sexually! active! male! and! female! annual! non;! culture!
o Child!pedestrian!injury!prevention!!!
test!for!gonorrhea!and!Chlamydia!!
o Child!helmet!use!!!
%
o Drowning!prevention!!!
%
o Burn!injury!prevention!!!
%
o Household!product!poisoning!!!
%
o Medicinal!poisoning!!!
%
o Watusi!poisoning!!!
%
!
%
%
%
%
%
%
%
%
%
% TP
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SCHEDULE%OF%VISITING% %
o Newborn%visit%!! PREVENTION%OF%CHILD%MALTREATMENT%!
• Hand! washing,! minimize! exposure! to! others,! SIDS! Child#Maltreatment#(WHO)#%
precaution,!safe!and!smoke;free!environment!! “All! forms! of! physical! and/or! emotional! ill;treatment,! sexual!
o First%week%visit%! abuse,! neglect! or! negligent! treatment! or! commercial! or! other!
• Avoid! prolonged! exposure! to! sun,! monitor! exploitation,!resulting!in!actual!or!potential!harm!to!the!child’s!
temperature,!sleeping!arrangements!!! heath,! survival,! development! or! dignity! in! the! context! of! a!
• Avoid!drinking!hot!liquids!when!holding!baby!!! relationship!or!responsibility,!trust!and!power”!!
o One%month%visit%!! *
• Safe! crib,! keep! small! and! sharp! objects! and! plastic! Risk*Factors*!
bags!away!from!crib,!test!temperature!of!bath!water!! o Individual!factors!in!parent!and!caregiver!in!the!child!!!
o TwoNmonth%visit%! o Relationship!factors!!!
• Never! shake! baby,! don’t! leave! baby! alone,! safe! ride! o Community!factors!!!
(not!in!front!seat),!clean!appropriate!toys!! o Societal!factors!!!
o Four%month%visit%! !
• Proper! use! of! car! safety! seat,! don’t! use! soft! toys,! Protective*Factors*!!
childproof! home,! use! safety! locks,! don’t! use! baby! o Good!parenting!!!
walkers,!check!sources!of!lead!! o Strong!attachment!between!parents!and!children!!!
o Six%month%visit%% o Positive!non;physical!disciplinary!techniques!
• Keep!in!high!chair/!play!pen,!avoid!burns,!avoid!choke! !
foods!! Republic#Act#761O#(AntiOChild#Abuse#Law)#
o 9%Months%to%9%Years%of%Age%visit% *!“The! head! of! any! public! or! private! hospital,! medical! clinical!
Check*for*the*ff.! and! similar! institution,! as! well! as! the! attending! physician! and!
• Age!appropriate!toys!!! nurse,! shall! report,! either! orally! or! in! writing,! to! DSWD! the!
• Car!safety!!! examination! and/or! treatment! of! a! child! who! appears! to! have!
• Childproof!home!!! suffered! abuse! within! 48! hours! from! the! knowledge! of! the!
• Caution!near!water,!pools!and!tubs!!! same.”!!!
• Pedestrian!safety!!! !
• Supervise!play!!! !
• Stranger!precautions!!! !
• Child!sexual!abuse!! !
o 10%to%19%years%Visit%
• Use! of! protective! sports! gear,! anticipate! errors! in!
judgment,! increased! risk;taking,! teach! non;violent!
conflict! resolution! techniques,! discuss! tobacco,!
alcohol!and!drugs!!
#
Counseling#on#Exposure#to#Lead#and#Other#Toxicants#!
o Lead! is! an! ubiquitous! environmental! toxicant! that! can!
attack!many!different!organ!systems,!the!most!studied!of!
which!is!cognition.!!
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TPMD%2017|PEDIATRICS%1%–%Preventive%Pediatrics%|! P a g e !4!!
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 IMMUNIZATION%
%
IMMUNIZATION%! Live(Attenuated(Vaccines(!
o The! process! of! inducing! immunity! against! a! specific! o Tend!to!induce!longAterm!responses!!!
disease!! o They! replicate,! often! similarly! to! natural! infections,!
1. Passive% –! through! administration! of! antibodyD% !until!an!immune!response!shuts!down!reproduction!!!
containing%preparations!!! o Mostly!administered!as!singleAdose!schedules!!!
2. Active% –! by! administering! a! vaccine% or! toxoid% to! o Repeat! dose,! like! MMR,! is! to! induce! an! initial! immune!
stimulate!the!immune!system!to!produce!a!prolonged! !response!in!persons!who!failed!to!respond!to!the!first!
humoral!and/or!cellular!immune!response!!! dose!!!
Passive! Active! !
Administration! of! Inactivated(Vaccines(!!
Injection!of!an!antigen!! o Tend! to! require! multiple! doses! to! induce! an! adequate!
preformed!antibody!!
immune!response!!!
Transplacental! transfer! of! Protection!produced!by!the!
o More!likely!to!need!boosters!to!maintain!immunity!!!
antibody!during!gestation!! person’s!immune!system!!
o Some!inactivated!vaccines,!however,!appear!to!!induce!
Protection! may! persist! for! longAterm! immunity,! perhaps! lifeAlong,! after! a! primary!
months!to!as!long!as!a!year! Usually!permanent!! series!!!
after!birth!! o Ex.!Hep!B!vaccine,!IPV!!
% (
Passive%Immunization%! Vaccine(!
o Provide!protection!to:! o Most! inactivated! vaccines,! including! DTaP,! Hep! A,! Hep! B,!
1. Immunodeficient!children!with!BAlymphocyte!!defects! Hib,! TIV,! PCV7,! MCV4,! and! Tdap,! are! administered!
who!have!difficulties!making!Antibody!!! intramuscularly!(IM).!!!
2. Persons! exposed! to! infectious! diseases! or! at! o Commonly! used! live! attenuated! vaccines,! MMR! and!
!imminent! risk! of! exposure! where! there! is! not! varicella,!should!be!dispensed!subcutaneously!(SC)!!!
adequate!time!to!develop!an!active!immune!response! o IPV!and!PPS23!(pneumococcal!polysaccharide!vaccine)!can!
to!a!vaccine!!! be!given!IM!or!SC.!!!
3. Persons! with! an! infectious! disease! as! part! of! specific! o IM!injections!for!infants!and!young!children!!!
therapy!for!that!disease!!! • Anterolateral!thigh!muscle!!
%
• Needle!length:!!
Active%Immunization%%
→ 5⁄8!in.!for!newborn!infants!!
o Immediate!goal:!prevention%of!disease!!
→ 1!in.!for!infants!2A12!mo/o!!
o Ultimate!goal:!eradication%of!disease!!
→ 1!to!1!1⁄4!in!for!older!children!
o Types!of!protection!induced:!!
o IM!injections!for!adolescents!and!adults!!
• Complete!protection!for!life!!!
• Deltoid!muscle!of!the!arm!!
• Partial!protection!(booster!doses)!!!
• Needle!length:!1!–!1!1⁄2!in!!
!
o Most!IM!injections!can!be!made!with!23A25!gauge!needles.!!
Vaccines(!!
o For!SC!injections,!needle!lengths!generally!range!from!5⁄8!
o Defined!as!whole!or!parts!of!microorganisms!administered!
to!3⁄4!inches!with!23A25!gauge!needles!
to!prevent!an!infectious!disease!!!
!
o Immunity! through! stimulation! of! antibody! formation,!
Contraindications(to(All(Vaccines(!!
cellular!immunity,!or!both!!!
o Serious! allergic! reaction! (anaphylaxis)! after! a! previous!
o Protection!mediated!primarily!by!BAlymphocytes!
vaccine!dose!!!
o Can!consist!of:!!!
o Serious!allergic!reaction!to!a!vaccine!component!!!
• Whole!inactivated!microorganisms!!
!
→ IPV,!Hepatitis!A!!
Deferral(!!
• Parts!of!microorganism!!
o Children! with! moderate! to! severe! acute! illnesses,! with! or!
→ Acellular!pertussis,!HPV,!Hepatitis!B!! without!fever,!until!the!child!recovers!!!
• Polysaccharide!capsules!! !
→ Pneumococcal!and!meningococcal!! Contraindications(to(All(Live(Vaccines(!!
• Polysaccharide!capsules!conjugated!to!protein!carrier!! o Immunocompromised!patients!!!
→ Hb,!pneumococcal,!and!meningococcal!! o Patients!given!immunoglobulin!and!blood!products!!for!the!
• Live!attenuated!microorganism!! past!3!months!!!
→ Measles,! mumps,! rubella,! varicella,! rotavirus,! o Pregnancy!and!possibility!of!getting!pregnant!within!!three!
influenza!! months!!!
• Toxoids!! o Household! contacts! of! immunocompromised!
→ Tetanus!and!diphtheria!!! patients!!(for!OPV!only)!!!
( !
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TPMD%2017|PEDIATRICS%1%–%Immunization%|! P a g e !1!!
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GENERAL%RULES%TO%GUIDE%IMMUNIZATION%DECISIONS%! !
1. Simultaneous%administration%of%multiple%vaccines%! !
o Vaccines! can! be! given! simultaneously! on! the! same! !
day,!whether!inactivated!or!live!!! !
o Safe!and!effective!!! !
o Immune!response!to!one!vaccine!generally!!does!not! !
interfere!with!other!vaccines!!! !
2. Interval%between%vaccines%! !
o Different!inactivated!vaccines!can!be!!administered!at! !!
any!interval!between!doses!!! ! !
o Different! live! attenuated! vaccines,! if! not!
!administered! on! the! same! day,! should! be! given! at!
least! 1! month! apart! because! of! theoretical! concerns!
about!viral!interference!!!
o An!inactivated!and!alive!vaccine!can!be!spaced!at!any!
interval!from!each!other!!!
3. Interchangeability%of%vaccine%products%!!
o Vaccines!have!been!considered!!
o Interchangeable! by! most! experts! when! administered!
according!to!their!licensed!indications,!although!data!
documenting! the! effects! of! interchangeability! are!
limited!!
4. Combination%vaccines%!
o Combination! vaccines! represent! one! solution! to! the!
issue!of!increased!numbers!of!injections!during!single!
clinic!visits!!
5. Intramuscular%route%of%administration%!
o Infants! and! young! children:! anterolateral! thigh!
muscle!!!
o Adolescents!and!adults:!deltoid!muscle!of!the!arm!!!
6. Lapsed%immunizations%!!
o A! lapse! in! the! immunization! schedule! does! not!
require!reAinitiation!of!the!entire!series!or!addition!of!
doses! to! the! series! for! any! vaccine! in! the!
recommended!schedule!!
7. Vaccine%safety%and%contraindications%!
o All!licensed!vaccines!in!the!US!are!safe!and!effective,!
but! no! vaccine! is! completely! safe! and! effective! in!
every!person!!!
o Some! vaccine! recipients! will! have! an! adverse! effect,!
and!some!will!not!be!protected!fully!!!
o Risks! of! immunization! may! vary! from! minor! and!
inconvenient!to!severe!and!lifeA!threatening!!!
o Immunization!providers!must!communicate!risks!and!
benefits!!!
8. Common%misconceptions%about%immunization%!!
o Evidence! from! several! studies! does! not! support! the!
associations! of! MMR! vaccine! and! autism,! as! well! as!
thiomerosalA!containing!vaccines!and!autism!
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TPMD%2017|PEDIATRICS%1%–%Immunization%|! P a g e !2!!
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 EXPANDED%PROGRAM%ON%IMMUNIZATION%(EPI)%by%the%Department%of%Health!
VACCINE%! MINIMUM%AGE%! DOSE%(NO)%! ROUTE/SITE% OF% MIN% INTERVAL% BET% REMARKS%!
ADMINISTRATION%! DOSES%!
BCG%1%! Birth;!OR!any!time! 0.05!ml!for!NB;!! Intradermal;!deltoid! ! Destroyed! by! heat! &!
after!birth!! 0.1! ml! for! infants! R!arm!! sunlight!!
(1)!!
DTP%! 6!weeks!! 0.5!ml!(3)!! IM;! upper! outer! 4!weeks!! Damaged! by! heat,!
portion!of!thigh!! freezing!!
OPV%! 6!weeks!! 2!drops!(3)!! PO;!mouth!! 4!weeks!! Easily!damaged!by!heat!!
IPV% 6!weeks!! 0.5!ml!(3)! IM!or!SC! 4!weeks! !
HiB% 6!weeks! 0.5!ml!(3)! IM;! anterolateral! 4!weeks! Easily!damaged!by!heat!
aspect!of!thigh! ! !
HEP%B%! 6! weeks! or! at! Follow! IM;! anterolateral! 0,1!&!6!months!! Destroyed! by! heat! or!
birth!! manufacturer’s! aspect!of!thigh!! freezing!!
instructions!0.5! ml!
(3)!!
ROTAVIRUS% 6!weeks! 2!ml! PO! RV1A2!doses! Lat! dose! should! ! de!
RV5!A3!doses! given! not! later! than! 32!
weeks!
!
PCV/PPV% 6!weeks! 1!ampule! IM! 4!weeks! Primary! vaccination! 3!
! doses!plus!booster!after!
6!months.!
Healthy! 2A5! yrs:! 1! dose!
PCV! 13! or! 2! doses! PCV!
10!
MMR% 12A15!months! 0.5!ml! SC! ! Easily!damaged!by!heat!!
BCG%2%! At! school! entry,! 0.1!ml!(1)!! ID;!L!deltoid!! ! Destroyed! by! heat! or!
w/! or! w/o! BCG! sunlight!!
scar!!
TETANUS% Women! of! childA! 0.5!ml!(5)!! IM;!deltoid!region!! TT1:!at!1st!contact!! Easily!damaged!by!heat!
TOXOID%! bearing!age!! TT2:! at! least! 4! wks! &! sunlight;! given! for!
!! !! after!TT1!! those!not!given!primary!
TT3! at! least! 6! wks! immunization!in!infancy!
after!TT2!! and!childhood!!
TT4! at! least! 1! year!
after!TT3!
TT5! at! least! 1! year!
after!!
% ! ! ! ! !
% ! ! ! ! !
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TP

TPMD%2017|PEDIATRICS%1%–%Immunization%|! P a g e !3!!
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BCG%VACCINE%! o Children! and! adolescents! who! have! not! been! vaccinated!
o 50%! effective! in! preventing! pulmonary! tuberculosis! in! with!Hep!B!vaccine!may!begin!series!during!any!visit!!
adults!and!children!!! o Contraindications:!!
o Has! 50–80%! protective! effect! for! disseminated! and! • Anaphylactic! reaction! to! a! previous! dose! or! to! a!
meningeal!tuberculosis!!! vaccine!component!!!
o Live!attenuated!bacterial!vaccine!!! o Adverse%Reaction:!!
o 0.05! ml! from! birth! A! 4! weeks;! 0.1! ml! beyond! 1! month! !A! • Pain!and!swelling!at!injection!site!!
intradermal!route!!! !
o First!dose!ideally!given!at!birth;!can!be!any!time!after!! DIPHTHERIA,%TETANUS%&%PERTUSSIS%(DTP)%VACCINE%!!
o Birth!at!the!right!upper!deltoid!!! (DTP%or%DTwP/DTaP)%!
o Booster!dose!at!school!entry,!at!left!upper!deltoid!! o Toxoids!
o For! healthy! infants! and! children! >! 2! mo/o! not! given! BCG,! o P!or!wP!is!killed/inactivated!whole!cell!pertussis!!!
PPD!prior!to!BCG!vaccination!is!not!necessary! o aP!is!killed/inactivated!acellular!pertussis!!!
o PPD!is!recommended!if!any!of!the!ff!is!present:! o 0.5!mL!intramuscularly!!!
• Suspected!congenital!TB! o Given!at!6,!10,!14!weeks;!12A24!mos;!4A6!y/o!!!
• History! of! close! contact! to! known! or! suspected! o The! fourth! dose! may! be! administered! as! early! as! age! !12!
rd !
infectious!case!of!TB! months,! provided! 6! months! have! elapsed! since! the! !3 !
• Clinical! findings! suggestive! of! TB! and/or! CXR! dose!!!
suggestive!of!TB! o Administer!the!final!dose!in!the!series!at!age!4!!!
o Contraindications:(! o Usual%Side%Effects%!
• Immunodeficiency! • Fever!up!to!72!hours!(low!to!moderate!grade)!!
• Progressive!dermatoses!! • Restlessness!and!irritability!!
o Adverse%Reactions:!! • Local! reaction:! pain! and! swelling! at! the! site! of!
• Abscess!at!the!site! injection!!
• Axillary!!lymphadenopathy!!! o Contraindications%!
• Encephalopathy!(coma,!prolonged!seizures!&!↓!level!
Usual% Accelerated%
! of!consciousness)!within!7!days!of!administration!of!a!
Reactions%! Reactions%!
previous!dose!!
Induration%! 2A4!weeks!! 2A3!days!!
• Progressive! neurologic! disorders:! infantile! spasm,!
Pustule%formation%! 5A7!weeks!! 5A7!days!!
uncontrolled!epilepsy,!progressive!encephalopathy!!
Scar%formation%! 2A3!months!! 2A3!weeks!!
• Severe! allergic! reaction! (anaphylaxis)! to! a! previous!
!
dose!!
HEPATITIS%B%VACCINE%!
o Precautions%!
o Inactivated!viral!antigen!!!
• Fever! greater! than! 40.5°C! within! 48! hours! after!
o 10!mcg!for!0!–!<!19!years!old;!20!mcg!for!≥!19!years!old!!!
administration!of!a!previous!dose!!!
o Given!at!0,!1!&!6!months!!!
• Collapse! or! shockAlike! state! within! 48! hours! after!
o Intramuscular!route!!!
receiving!a!previous!dose!!!
o Schedule:!!0,!1!&!6!months!
st • Seizures!within!3!days!of!administration!of!a!previous!
• 1 !dose!is!given!within!12!hours!of!life!
st dose!!!
• The!hep!b!birth!dose!maybe!used!as!the!1 !dose!in!!
• Persistent,!inconsolable!crying!lasting!for!3!hours!and!
• A!3Adose!primary!series,!at!least!4!weeks!apart.!
th within!48!hours!after!receiving!a!previous!dose!!!
o A!4 !dose!is!needed!for!the!following:!
rd • Moderate! or! severe! acute! illness! with! or! without!
• If!the!3 !dose!is!given!at!age!<!6!months!
fever!!!
• If! no! birth! dose! is! given! using! the! EPI! schedule! of! 6,!
!
10,!14!weeks!
POLIOMYELITIS%VACCINE%!!
• For! preterms! <! 2kgs,! the! initial! dose! should! not! be!
o Oral(Polio(Vaccine((OPV)(!!
counted!in!a!3Adose!immunization!schedule! !!
• Live!attenuated!(Sabin)!!!
o If!mother!is!HBsAg%(+):!!!
• 0.5!ml!or!2!drops!(using!multiple!dose)!orally!!!
• Give!HBIG!&!Hep!B!vaccine!within!12!hours!of!birth!!!
• Given!at!6,!10,!14!weeks;!12A18!months;!4A6!y/o!!!
o If!mother’s!HBsAg!status!is!unknown:!!!
o Inactivated(or(Killed(Polio(Vaccine((IPV)(((
• Give!Hep!B!vaccine!within!12!hrs!of!birth!!
• 0.5!mL!intramuscularly!!!
• Test!for!the!mother’s!HBsAg:!!
• Given!at!2,!4,!6A18!months!and!4A6!years!!!
• If!(+),!give!the!infant!HBIG!(no!later!than!age!1!week)!!!
• IPV! was! recommended! to! decrease! the! incidence! of!
o If!mother’s!HBsAg!is!negative:%!
vaccineAassociated!paralytic!polio!(VAPP)!!!
• Give! Hep! B! vaccine! within! 12! hrs! of! birth! or! before!
• The!final!dose!in!the!series!should!be!administered!on!
discharge!!!
or! after! the! 4th! birthday! or! at! least! 6! months!
o Birth!dose!is!critical!for!children!born!to!mothers!who!are!
following!the!previous!dose!!!
HBsAg!(+)!or!whose!immune!status!is!unknown!!!
• If! 4! doses! are! administered! prior! to!
o Infants! born! to! HBsAg! (+)! mothers! should! be! tested! for!
age! 4! years,! the! 5th! dose!
HBsAg! and! antiAHBs! 1! to! 2! months! after! completion! of! at!
should! be! administered! at! TP
least!3!doses!of!Hep!B!series,!and!at!age!9A18!mos!!!
age!4!through!6!years!!!

TPMD%2017|PEDIATRICS%1%–%Immunization%|! P a g e !4!!
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o Absolute%contraindications%!! o Contraindications:!!
• Altered!immune!states,!those!on!antineoplastic!drugs,! • Same!as!other!live!vaccines%
high!dose!steroid,!radiation,!HIV/AIDS!!! %
• Pregnancy!!! VARICELLA%VACCINE%!!
• Household!contacts!of!immunocompromised!patients!! o Live!attenuated!viral!vaccine!!!
• Relative!contraindications:!vomiting!and!diarrhea!! o 0.5!ml!subcutaneously!!!
st
o Adverse%Reaction:!! o 1 !dose!at!age!12A15!months!!!
nd
• Paralysis!!! o 2 !dose!routinely!at!age!4!through!6!years,!may!be!!given!
( before! age! 4! years! provided! at! least! 3! months! !have!
st
H.(INFLUENZAE(TYPE%B%CONJUGATE%(HIB)%VACCINE%! elapsed!since!the!1 !dose!!!
o Polysaccharide!protein!conjugate!!! o Prevents!moderate!to!severe!cases!of!chickenpox!!!
o 0.5!ml!intramuscularly!!! o For! children! aged! 12! months! to! 12! years,! the! minimum!
o Given&at!6,!10!,14!weeks;!1A5!y/o! interval!between!doses!is!3!months!!
o Hib!vaccine!conjugated!to!either!tetanus!toxoid!(PRPAT)!or! o For!persons!aged!13!years!and!older,!the!minimum!interval!
CRM197!–!4Adose!series! between!doses!is!28!days!!
nd
o Hib!vaccine!conjugated!to!meningococcal!outer!membrane! o However,! if! the! 2 ! dose! was! given! at! least! 28! days! after!
nd
protein!(PRPAOMP)!–!3Adose!series! the!2 !dose,!it!can!be!accepted!as!valid!!
o DTaP/Hib! combination! products! should! not! be! used! for! o Can! be! given! within! 5! days! of! exposure! to! a! person! with!
primary! immunization! but! can! be! used! as! boosters! varicella!infection!!
following!any!Hib!vaccine!in!children!aged!≥!12!months.! o Safety%of%Varicella%vaccine%!
o Reactions:%% • The! virus! is! so! weak! that! it! is! not! transferred! from!
• Low!grade!fever!(2%)! someone!who!got!the!vaccine!to!another!person!!!
• Pain!and!swelling!(10A15%)!! • It!can!be!given!to!children!who!are!living!in!the!home!
! of!someone!whose!immune!system!is!weak!!!
MEASLES%VACCINE%!! • May! also! be! given! to! patients! whose! mother! is!
o Live!attenuated!!! pregnant!!!
o 0.5!ml!subcutaneously!!! o Reactions%!
o Recommended!at!age!9!months!but!may!be!given!as!!early! • May!develop!few!varicellaAlike!lesions!and!fever!2!to!3!
as!6!months!in!cases!of!outbreaks!!! weeks!or!as!long!as!after!1!month!after!vaccination!!!
o Adverse%reactions%!! • May! also! develop! shingles! although! the! incidence! is!
• Fever! with! or! without! rashes! 5A12! day! after! less! frequent! and! less! severe! as! compared! to! the!
administration! actual!varicella!infection!!!
• Hypersensitivity!reaction!!! !
o Contraindications:!!! HEPATITIS%A%VACCINE%!!
• Immunocompromised!state!!! o Inactivated!viral!antigen!!!
• Pregnancy!!! o 2!doses!intramuscularly!at!least!6!months!apart!!!
• Relative% Contraindication:! untreated! active! TB! o Dose:%%
!through!6!years!! • 1A18!years!old!A!720!U!(0.5!mL)!!
! • >19!years!old!A!1440!U!(1.0!mL)!!
MEASLES,%MUMPS,%RUBELLA%(MMR)%VACCINE%! o Age!≥!1!year!!
o Live!attenuated!viral!vaccine!!! o Reactions:!!
o 0.5!ml!subcutaneously!!! • Pain!and!local!swelling!!
o Given!at!12A15!months;!booster!dose!at!4A6!years!old!!! o Indications%!
o Administer! the! second! dose! of! MMR! routinely! at! age! 4! • All!children!12A23!months!old!!!
through!6!years,!but!may!be!administered!earlier!provided! • Persons! traveling! to! areas! with! high! prevalence! of!
at!least!28!days!have!elapsed!since!the!first!dose!!! Hepatitis!A!!!
o If! not! previously! vaccinated,! administer! 2! doses! of! MMR! • Occupational!hazards!!!
during!any!visit!with!≥!4!weeks!between!doses!!! • Hemophiliacs!–!contacts!of!infected!persons!!!
o Reasons%for%giving%2%doses%of%MMR:%!! • When!immunity!against!Hepatitis!A!is!desired!!!
• Only!87A90%!of!children!actually!receive!the!measles! %
vaccine!!! INFLUENZA%VACCINE%!
• 5%! of! children! who! receive! the! first! vaccine! won’t! o Inactivated!viral!vaccine!!!
develop!immunity!!! o Dose:%%
• Children! who! had! an! immune! response! to! the! first! • 6!A!35!months!A!0.25!mL!!!
dose!could!get!a!“booster”!effect!!! • ≥!3!years!old!A!0.5!mL!!!
o Reactions%!! o Intramuscularly!or!subcutaneously!!!
• Fever! with! or! without! rash! (5A14! days! after! o Administered!annually!to!children!aged!6!mos!A!18!yrs!!!
administration!(measles)!!! o Administer! 2! doses! at! least! 4! weeks! apart!
• Swelling!of!parotid!gland!(mumps)!!! to! children! !<! 9y/o! who! are! receiving!
• Transient! arthritis! or! arthralgia! and! postAauricular! the! vaccine! for! the! first! time! OR! TP
lymphadenopathy!(rubella)!! who! were! vaccinated! for! the!

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 first! time! during! the! previous! influenza! season! but! only! !
received!1!dose!!! ROTAVIRUS%VACCINE%!
o Should! be! administered! at! least! once! a! year! before! the! o Inactivated!vaccine!!!
start!of!flu!season!(Feb!to!June)!!! o 0.5!mL!intramuscularly!!!
o Indications%!! o Given!at!2,!4,!and!6!months!old!,!minimum!interval!is!at!4!
• All!children!6!months!to!59!mo/o!!! weeks!
• Children!≥60!mo/o!with!the!ff!conditions:!! o Administer!the!first!dose!at!age!6!to!14!weeks!!and!16!days!
→ Chronic!cardiovascular!disease!!! o Vaccination! should! not! be! initiated! for! infants! 15! !weeks!
→ Chronic!pulmonary!disease!including!asthma!!! and!0!day!or!older!!!
→ Chronic!metabolic!disorders!including!DM!!! o The! maximum! age! for! the! final! dose! in! the! series! is! 8!
→ Chronic!renal!disorders!!! !months!and!0!day!!!
→ Immunocompromised! including! HIV/AIDS,! o There! is! potentially! higher! risk! of! intussusception! !when!
st
hemoglobinopathies!!! the!1 !dose!is!given!beyond!the!recommended!age!!!
• Children!on!long!term!salicylate!therapy!!! %
• All!household!contacts!of!#1A3!!! HUMAN%PAPILLOMAVIRUS%(HPV)%!
o Inactivated!vaccine!!!
• Adult!over!60!years!!!
o 0.5!mL!intramuscularly!!!
!
o Most! effective! for! both! males! and! females! when! !given!
PNEUMOCOCCAL%VACCINE%!
before!exposure!to!HPV!through!sexual!contact!!!
o Pneumococcal(conjugate(vaccine((PCV7)(!
o Bivalent(HPV((HPV2:(HPV(16,(18)(!!
• Polysaccharide!capsules!conjugated!to!protein!carrier!!
• For! the! prevention! of! cervical! preAcancers! and!
• 0.5!mL!intramuscularly!!!
cancers!!
• Minimum!age!of!6!weeks!
• 0,!1,!6!months!
• Given!at!2,!4,!6!and!12!A24!months!OR!!!
o Quadrivalent(HPV((HPV4:(HPV(6,(11,(16,(18)(!!
• 1! dose! to! all! healthy! children! aged! 24A59! mo/o! who!
• 0,!2,!6!months!
!are!not!completely!vaccinated!for!their!age!!!
• For!the!prevention!of:!!
o Pneumococcal(polysaccharide(vaccine((PPV23)(!!
→ Cervical!preAcancers!and!cancers!!!
• Polysaccharide!capsules!!!
→ Vaginal!and!vulvar!cancers!!!
• 0.5!mL!intramuscularly!!!
→ Genital!warts!in!females!and!males!!
• For!children!≥!2!yrs!!!
• Schedule:%%
• Recommended! for! certain! high! risk! infants! ≥! 2! yrs/o! st
→ 1 !dose!to!females!11!or!12!y/o!!
in!addition!to!PCV! nd st
→ 2 !dose!1A2!months!after!the!1 !dose!!
• For!healthy!children,!no!additional!doses!are!needed! rd! st
is!PCV!series!is!completed! → 3 dose! 6! months! after! the! 1 ! !(at! least! 24!
nd
o Pneumococcal(polysaccharide(vaccine(!! weeks!from!the!2 !)!!
o Administer!the!series!to!females!aged!13!through!18!!if!not!
• Administer!PPSV!2!or!more!months!after!the!last!dose!
previously!vaccinated!!
of! PCV! to! children! 2! years! or! older! with! certain!
o HPV4! may! be! administered! in! a! 3Adose! series! to! males!
underlying!medical!condition!to!provide!immunity!to!
!aged! 9! through! 18! years! to! reduce! the! likelihood! of!
serotypes!not!contained!in!the!PCV7!!!
acquiring!genital!warts!!!
• A!single!reAvaccination!should!be!administered!after!5!
!
years!to!children!with!anatomic!or!functional!asplenia!
!
or!an!immunocompromising!condition!!!
!
o Conjugate%vaccines%(Hib,%PCV7,%&%MCV4%)%!!
!
• T!lymphocyte–dependent!vaccines!!!
!
• Induce!good!immune!responses!even!in!young!infants!
!
• Induce!higher!avidity!Antibody,!immunologic!memory!
!
!leading! to! booster! responses! on! repeat! exposure! to!
!
the! Ag,! longAterm! immunity,! and! herd! immunity! by!
!
decreasing!carriage!of!the!organism!!
!
o Polysaccharide(antigens((PPV23,(MPSV)(!
!
• Induce! BAlymphocyte! responses! in! the! absence! of! TA!
!
lymphocyte!help!!!
!
• Associated! with! poor! immune! responses! in! children!
!
<2!yr!of!age,!shortAterm!immunity,!and!absence!of!an!
!
enhanced!or!booster!response!on!repeat!exposure!to!
!
the!antigen.!!
!
o Indications%!
!
• Routinely!for!children!2!months!and!above!!!
!
• Patients!undergoing!splenectomy!!! !
• Cochlear!implants!!! !
• Cerebrospinal!fluid!leaks!!! TP
!
• All!conditions!listed!for!influenza!!!
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VACCINES%FOR%SPECIAL%GROUPS%! exposure!!!
( • Any!exposure,!regardless!of!severity!after!completion!
TYPHOID(VACCINE(! of!the!primary!series,!should!be!given!rabies!vaccine!!
o Inactivated!vaccine!!! !!
o 0.5!mL!intramuscularly!!! With%exposure%!
o Single! dose! given! as! early! as! 2! years! of! age! with! !Interval%from%last%dose%! Booster%!
revaccinaton! every! 2! to! 3! years! if! there! is! continued! 0A6!months!! 1!booster!dose!!
exposure!to!S.%typhi%!! >6!months!to!3!years!! 2!booster!doses!(D0!and!D3)!!
o Indications%!! Full! course! (D0,! 3,! 7,! 14,! 28)!
Travellers!to!areas!where!there!is!risk!of!exposure!to! >!3!years!!
• without!Rabies!Ig!!
!S%typhi%!! !
• Persons!with!frequent!contact!to!S%typhi%!! ! !
(
MENINGOCOCCAL(VACCINE(!
o Inactivated!vaccine!!!
o 0.5!mL!intramuscularly!!!
o Single!dose!for!all!children!≥!2!years!known!to!be!at!high!
risk!for!disease!
o Infants!<!2!y/o!(minimum!of!3!mo/o)!may!be!given!2!doses!
of!the!vaccine!3!months!apart!in!!outbreak!situations.!
o Indications%!!
• Children!aged!2!through!10!years!with!the!ff:!!
→ Persistent!complement!component!!deficiency!!!
→ Anatomic!or!functional!asplenia!!!
→ Part!of!the!outbreak!control!program!!!
• Persons! aged! 11! through! 18! years! if! not! previously!
vaccinated!!!
• Previously! unvaccinated! college! freshman! living! in!
dormitory!!!
%
MENINGOCOCCAL%VACCINE%(MPS4)%!
nd!
o Administer! a! 2 dose! to! persons! previously! vaccinated!
st
who! remained! at! increased! risk! after! 3! years! (if! 1 ! dose!
st
given! at! age! 2A6! yrs)! or! after! 5! years! (if! 1 ! dose! given! at!
age!7!years!or!older)!!
o Persons! whose! only! risk! factor! is! living! in! onAcampus!
housing! are! not! recommended! to! receive! an! additional!
dose!!!
!
RABIES%VACCINE%!!
o AntiDRabies%Act%2007%!
• Recommended! routine! rabies! preAexposure!
prophylaxis! for! children! aged! 5A14! years! in! areas!
where! there! is! high! incidence! of! rabies!(incidence! >!
2.5!human!rabies/million!population)!!!
• From! Jan! to! Sept! 2007,! areas! with! highest! incidence!
for!rabies:!!Regions!2,!5,!7,!8,!9,!10!CAR!CARAGA!!
o Two% recommended% regimens% for% preDexposure%
prophylaxis:%!!
• Intramuscular%dose%!!
→ PVRV!0.5!mL!or!PCEC!1.0!mL!on!deltoid!area!on!
D0,!7,!!21,!28!!!
• Intradermal%dose%!!
→ PVRV!or!PCEC!0.1!mL!in!deltoid!area!on!D0,!7,!21,!
28!!!
• It! should! not! be! given! in! gluteal! area! because!
absorption!is!unpredictable!!!
• A! repeat! dose! should! be! given! if! vaccine! is!
administered!subcutaneously!!!
• Booster! doses! are! not! mandatory! but! may! be! given! TP
every! 3! years! depending! on! continuing! risk! of!

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