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General Pediatrics

Michael Davis, M.D.

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General Pediatric Care

General pediatric care consists of the process of diagnosing the problems

which adversely impact the health of children--followed by providing care which

minimizes disease and optimizes the potential of each child.

General pediatrics involves assessment a the child, with or without a medical

complaint.

Children depend upon the general pediatrician to recognize their problems. In general pediatrics their problem often hasn’t yet even been recognized. As general pediatricians

we first we observe; we see a child for one thing but we observe them for other problems. Second, we anticipate problems; we know what to expect so we can give guidance

about anticipated problems. The third thing we do is screen for hidden problems.

General pediatrics involves detecting the problems that are going to hurt children. Sometimes children come to you for routine care but other problems are recognized by

the astute clinician.

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Objectives of Presentation

# Discuss a variety of General Pediatric Topics

# Stress use of observational skills

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Screening Test

# A screening test must be able to be used in a large population to detect

individuals with early, mild or asymptomatic disease.

< The disease must be relatively common

< Morbidity is substantial

< Test implementation is achievable

< Intervention is available

A screening test is a test that is use in a large population to detect individuals who have mild, early or asymptomatic disease. Before they normally would come to recognition.

There are four things you need for a good screening test. There has to be a disease that is relatively common, it has to be something that hurts children. The morbidity has to be

substantial. You have to have a test that is affordable. And then there has to be some intervention available, so that if you find a problem, you have something to offer.

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Sensitivity of the Screening Test

# Sensitivity: Refers to the proportion of individuals with disease who are

detected by test. (ie, test is abnormal).

# Specificity: Refers to the proportion of individuals without disease who are

correctly identified by test (ie, test is normal).

Sensitivity means refers to the proportion of all the individuals who have the disease, how sensitive is this test to detect those who

have it. Where specificity means the proportion of those who don’t have the disease, who will come out negative. So we don’t want

a whole lot of false positives.

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A four month old male is new to the area and is brought in for

immunizations. Birth hx is normal and birth weight was 7 lbs. 4 oz.

Today's growth parameters:

Wt- 4.3 kg

Ht - 56 cm

OFC - 40 cm

First one: four month old brought to your office, for baby shots. His birth rate, the birth history was normal, he weighed

7 lbs. 4 oz. And today at four months of age he weighs 4.4 kg, height 57 cm and his head size is 40 cm. What’s the

problem? He’s not growing.

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Inadequate Growth

# Adequate growth depends on adequate calories

being provided, absorbed, and utilized.

# Inadequate growth is frequently linked to poor

development.

# The term "failure to thrive" is a descriptive term

rather than diagnosis.

The concern is that this child has had

inadequate growth. The point that adequate

growth does depend upon the child getting

adequate calories, absorbing adequate

calories and utilizing them. Inadequate

growth is frequently linked to poor

development. The child who isn’t growing,

whose muscles mass is inadequate, will

often be developmentally delayed. So you

have this term, “Failure to thrive”. It’s

usually used when a child is not growing

and is developmentally not doing quite what

they should be doing. The term is a

descriptive term and not a diagnosis. You

really shouldn’t diagnose failure to thrive.

You should be describing it and then finding

out what the diagnosis is.

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Normal Weight Pattens

# Fetal weight triples during third trimester

# Birth weight average 7 lbs

# Birth weight regained by day 14

# Birth weight doubles at 4 too, triples at 12 mo,

quadruples at 24 mo.

# First year gain/day:

0-6 mo = 20 gm

7-12 mo = 15 gm

# Second year gain/month = 0.25 kg/month (1/2

lb/month)

# Memory Aids:

age 2-6: gain/year is 5 lbs.

Wt (lbs) = 17 + (5 x age)

age 7-12: gain/year is 7 lbs.

Wt (lbs) = 5 + (7 x age:)

Chart of normal growth patterns.

The fetus in the last trimester is in the most

rapid period of growth of it’s entire life.

The fetus will triple it’s weight in the third

trimester. The average birth weight is 7 lbs.

Most babies lose a little weight after birth.

The average baby should be back at birth

weight no later than two weeks. He will

regain his birth weight in 14 days. The birth

weight doubles at four months, triples at 12

months and quadruples at 24 months.

In the first six months, the average child

gains 20 grams a day. Then the weight

slows up a little bit and the average child in

the second half of his first year will gain 15

gms a day. And then by the second year of

life they are only gaining 250 grams per

month. Children the first year of life will

come in and everyone will stress weight

growth and then after the first birthday, the

weight slows up. And we don’t care so

much.

Between the ages of two and six the average

child will gain five pounds a year. And be-

tween the ages of seven and 12, they will

gain seven pounds a year.

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Normal Length and Height Pat-

terns

# In the first year, length increases by 50%

Normal Length and Height Patterns

Inches Cm.

Birth 20 50

Year 1 30 75

Year 2 34 87

# Birth length doubles by 4, triples by 13

# During year 2, gain/yr =12 cm (5-6 in)

Years > 2, gain/yr = 5.5 cm (2-2 1/2 in)

# Memory Aid:

After age 2, Ht (in) = 30 +(2.5 x age)

For lengths, the numbers are 20, 30 and 35

length. The most average child is 57 cm at

birth, and they grow 50% of that, 75 cm by a

year. Another 50% of that, 87½ when he’s

two. The birth length doubles by the time

he’s four. It depends on genetically and ado-

lescence, but roughly it triples by the time

he’s started puberty.

During the second year of life you gain five

or six inches and after that you only gain

two or 2 ½ inches a year.

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Head Circumference Patterns

Average Head Circumference Growth

1-3 mo 5 cm

3-6 mo 4 cm

6-9 mo 2 cm

9-12 mo 1 cm

Average Head Circumference by Age

birth 34 cm

yr l 46 cm

adult 55 cm

The head circumference is very important.

In the first year the average baby is born

with a birth head circumference of 34. But

that is modified by molding. The first three

months they gain 5 cm. The next three

months, 4 cm. The next three months, 2 cm.

And the next three months 1 cm. The aver-

age child’s head will grow up 12 cm in its’

first year of life. When that brain growth in

that first year of life compares to the rest of

the brain, so the average adult head circum-

ference is 55.

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Failure to Thrive

## Failure to thrive (FTT) can be caused by organic

factors (caused by medical diseases), or

nonorganic factors (caused by social/environmental

issues), or mixed.

# The cause of most FTT is nonorganic.

# Inadequate calories are often linked to ignorance,

dysfunctional parent/child interaction, poverty,

abuse or neglect, or poor feeding practices.

# Babies less than 6 months old usually improve

when calories are given.

“Failure to thrive”. It is important to deter-

mine whether it’s due to a medical disease,

or not a disease. It may be caused by social

or environmental diseases, or it may have a

mixed etiology. The cause in this country,

the most common cause of a child not grow-

ing, failure to thrive, is non-organic. It’s

environmental usually. Inadequate calories

provided to a baby is often linked to igno-

rance. Dysfunctional parent/child relation-

ship. Poverty and poor feeding practices.

For most children who are failing to thrive

under six months, the cause is psychosocial,

if the environment is changed, most of

those children will regain their growth

pretty easily. Sometimes if they are over

that age they don’t respond as well to the

simple practice of giving calories.

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A six month old is seen for routine child

care. He is noted to have a normal

weight and height and an OFC of 38 cm.

The mother has noticed that the child

does not have as many

skills other infants his age.

Six month old, routine child care. His prob-

lem is his head. It’s 39 cm. And we already

talked about them, they are supposed to gain

that measurement in the first three months.

He’s six months old. The mother has re-

cently enrolled him and now that she is

comparing him with other children, she is

worried that he doesn’t have as many skills

as other infants.

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Microcephaly

C Microcephaly is defined as a head circumference

<3 standard deviations below the mean.

Microcephaly is classified as primary (genetic) or

secondary (acquired).

" Causes of Primary Microcephaly

- Familial/autosomal dominant

- Chromosomal

" Causes of Secondary Microcephaly

- In utero exposures (radiation, alcohol)

- Maternal disorders [metabolic (diabetes),

hypothermia]

- Congenital infection

- Anoxia vascular event

- Perinatal insult

- Meningitis

The issue? His head is small. So we’ll talk

a little bit about microcephaly. It’s usually

defined as 3 standard deviations below the

mean. It’s broken down in two parts called

primary and secondary. Primary

microcephaly are those for which there is

sort of a genetic, familial or chromosomal

cause. And secondary is there is an event

that causes it. The most common causes of

acquired microcephaly are things that hap-

pen in utero. Possibly fetal alcohol syn-

drome, possibly a maternal disorder. Nature

is pretty good about keeping a pregnant

woman from hurting her baby, but congeni-

tal infections, anoxia, vascular events,

perinatal insults and meningitis may cause

microcephaly.

This is one we’ve all seen. A child whose

head is growing normal, there’s a hostile

event, following that microcephaly occurs.

Shaken baby syndrome may cause

microcephaly. Some shaken babies get hy-

drocephalus, but this baby had a lot of brain

tissue trauma.

This is another child. This is the pattern of

primary or congenital microcephaly. A child

whose head size just never grows. And this

child has a very high chance, more than

50%, of having a developmental delay. And

although the small head could possibly be

attributable to a small child, microcephaly

may occur in a child who is not going to be

neurologically normal.

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Developmental Disability

! Risk factors for developmental disability may be

suggested by the history:

" Prenatal: in utero exposures or events

" Perinatal: birth and neonatal course

" Postnatal: meningitis

! The physical exam may reveal risk factors for

developmental disability, such as chromosomal

abnormalities or microcephaly.

! Parental concerns are often accurate predictors of

disabilities.

Prevalence of Disabilities (per 1000)

Cerebral palsy 2-3

Visual impairment 0.3 - 0.6

Hearing impairment 0.8-2

Mental retardation 20-30

Severe mental retarda- 3-4

tion

! The Denver Developmental Screen II is a com-

monly used screening tool for developmental

disability.

! Parent survey tools may be underutilized

! Measurements attempted in categories

Some populations are at risk for develop-

mental disability simply by their history.

They’ll have prenatal injury. Something

happened when they were born. Something

happened after they were born that puts

them at risk for developmental delay. Some

populations are at risk. The babies they

have, have become so large, not only do

they have hydrocephalies. They are at risk

just by exam. Then there are those children

who just aren’t doing well. We see it, the

parents see it. And parents who come in

have told me their children are not normal.

Because most parents tend to sort of exag-

gerate their children’s ability and tend to

sort of see the bright side. However, when

parents are worried about their children,

that’s a pretty good red flag that there is a

problem.

As far as developmental issues, an approxi-

mate prevalence of disability in 1000 chil-

dren is something like this: cerebral palsy

2-3 per thousand, visual impairment/hearing

impairment 2 per thousand. Mental retarda-

tion depends on how you define it obvi-

ously, but for severe mental retardation

about 3-4. All children need periodic assess-

ment of overall development. We do need

screening tools.

The most common screening tool is the

Denver Developmental II, which is the one

everyone accepts. But these are pretty time-

consuming. There’s a lot of concerns about

their usefulness. So parent surveys could be

underutilized.

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" Gross Motor skills - large body muscles

" Fine Motor skills - small hand muscles

" Cognition- thinking, memory, learning

" Language - comprehension communication

" Social/emotional - interactions, reactions with

other persons

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Developmental Assessments

28 week cognitive skills:

# Approach and grasp rattle with one hand

# Hold object and grasp for another

# Hold two cubes more than momentarily

# Bang bell on table

# Shake rattle, hold bell

# Transfer from one hand to another

24 month language skills:

# Uses 3 word sentences

# Uses “I,” “me,” and “you”

# Names three picture cards

# Names two test objects

# Knows four directional commands

The development and behavioral assess-

ments are linked to the very young child.

You usually break down your measurements

to the gross motor, fine motor, language and

social/emotional. And then some of the

scales include another, cognition. Particu-

larly if your child is a little bit older. And

these are the important things. And it’s sort

of independent. You all know the child who

has gross motor problems that have fine

motor skills that are normal. Okay. You all

know the children. It’s kind of comic that

babies are almost totally uncoordinated at

birth. That their bodies are totally controlled

by this primitive brain stem reflexes and

that you have to make the cortex to grow to

inhibit those reflexes and then take over.

This is just a normal baby of about two

months, this is sort of a normal prone posi-

tioning. And yet any pediatrician knows

that some of the skills we are looking for

are: sitting, three months, six months, seven

months.

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A one month old baby is seen for a

routine checkup. The left eye appears watery

and has a slight amount of yellowish drain-

age.

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Nasolacrimal Duct Obstruction

# Caused by incomplete lacrimal duct canalization

# Occurs in 5% of newborns

# Usually self-limited, resolves age 6-12 months

# Sx: tearing, mucoid material, crusting

# May predispose to bacterial conjunctivitis

# Treatment:

- Massage is applied upward over the lacrimal duct.

- Topical antibiotics are used if the eye is infected.

Blocked nasolacrimal duct. It’s caused by

an incomplete canalization, which almost

always improves on it’s own. It occurs in

5% of newborns, and it is usually self-lim-

ited. They get tearing, mucoid material,

crusting. It can predispose to bacterial con-

junctivitis. But the treatment is really reas-

surance and time. Massaging upwards

should be recommended to drain the

blocked duct. Topical antibiotics are pre-

scribed if the discharge gets purulent.

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Strabismus

# Defined as abnormal eye alignment

# Occurs 4% of children <age 6

# Causes:

- Ocular pathology

- Cranial nerve abnormalities

- Muscle weakness

# Morbidity: vision in one eye suppressed, resulting in

amblyopia ("lazy eye")

# Terms:

- Tropia - deviation always present

- Phoria - latent deviation (tendency)

# Two test techniques:

- For tropia - corneal light reflex test

- For phoria - cover test (2 components)

# Cover-uncover

# Alternating cover

Strabismus. When the eyes are not aligned

right, 4% of children up to age 6 have ab-

normal eye alignment. It is caused by either

the eyes don’t work, or the nerves don’t

work, or their muscles don’t work. The

problem is that if their eyes don’t focus to-

gether, vision in one eye is suppressed. The

result is amblyopia or lazy eye. Tropia

means that the deviation is always present.

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Corneal Light Reflex Test

"Hirschberg test"

Esophoria, exophoria, means that most of

the time the child will overcome it by con-

centrating and using muscles. These kids

tend to get headaches and when they are

tired their eyes will start crossing. For tropia

is diagnosed with the corneal light reflex

test, and phoria is diagnosed with the cover

test. If you work the eyes are aligned to-

gether and shined the distance of light and

look at its placement in the pupil. And

sometimes you have to look. It can be sub-

tle.

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Eye Cover Test

A. Cover/Uncover

B. Alternate cover

Esophophoria

When eye covered, eye deviates

When uncovered, eye returns to center

Where it’s misplaced in one eye and you

see that there is a permanent slight

exotropia or esotropia, based upon the light

test. As far as the diagnosis, you typically

will cover one eye and the child who has a

lesser weakness, if it’s covered for a long

time, the eyelid also deviates some way.

And as soon as you take the cover off, it will

correct itself. So you are looking for a subtle

little correction. And you can even do a

cover/uncover test of one eye or you can

alternate covering the two eyes. And again,

what you are looking for is that the pupil has

a slight flick of the eye pupil of the child

corrects once both eyes are open.

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A mother in your practice has just had a baby

with a unilateral cleft lip and cleft palate.

One of your mothers has just had a baby

with a cleft lip and palate. The parents are

obviously anxious and upset.

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Cleft Lip and Palate

# Incidence: Cleft lip (+/- palate) 1:600

Cleft palate 1:1000

# Genetics play a role

# Thirty percent have associated anomalies

# Need referral as soon as possible

- Obturator for palate to control fluids

- Early efforts are made to align arch segments

- Feeding difficulties should be treated

# Future Complications

- Recurrent otitis media

- Hearing loss

- Dental. Malposition of teeth and excessive dental

decay

- Speech defects

- Cosmetic concerns

One of the issues with a cleft lip and palate,

typical number is 1:730. Cleft palate, genet-

ics play a role in about half of the cases.

Thirty percent will have other associated

anomalies. You do need to refer these chil-

dren as soon as possible to a specialized

team. Because they work on fixing the pal-

ate so the child can eat.

The children who have cleft lips and palates

still have complications. They all are predis-

posed to otitis media. Most places do put in

bilateral tubing prophylactically. They are

still at risk for hearing loss, although less so.

If they are watched properly to make sure

they don’t have too many problems with

fusion. They are still going to have risk of

dental problems with the malocclusion,

malpositioning of their teeth. Some of them

will still have speech defects and cosmetic

concerns.

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A five month old develops white plaques

cover the palate and

buccal surfaces after taking antibiotics for an

ear infection.

A five month old goes to the ER. Has fever.

Given antibiotics. When he comes to you he

has white plaques covering his mouth.

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Oral Candidiasis

# Thrush is diagnosed in 2-5% of newborns

# It is common until age 6 months, occasional until age 12

months.

# Predisposing factors include use of antibiotics, maternal

breast colonization, contaminated objects (vitamin

dropper)

# Candidiasis is a indicator of immunodeficiency if it is

severe or late appearing (eg, HIV)

This is obviously thrush. He’s got thrush.

Thrush is Candida or Candidiasis. It’s diag-

nosed in 2% - 5% of newborns. It’s com-

mon until six months of age. Occasionally

you will see it until 12 months of age, par-

ticularly if they are on antibiotics. Some-

times there are other predisposing factors.

Maternal breast colonization of breast-feed-

ing babies. Thrush is a flag for immunode-

ficiency. If severe or if it appears late.

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The mother of a newborn asks what

she can do to prevent tooth decay

in this child.

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Fluoride Supplementation

# Supplementation is important in prevention of dental

caries

# Supplements are rarely needed if the community water

supply is optimal (0.7-1.0 ppm)

# Supplements are not necessary infants less than 6

months of age or for breast-fed infants

# Dosage of supplement (.25, 0.5,1.0 mEq.) depend on

age and water concentration

# Excess fluoride causes dental staining, such as with

overuse of toothpaste

The issue is fluoride. Supplements are

rarely needed if your community water sup-

ply is optimal. We usually give supplements

to breast-feeding babies, but they probably

don’t need it. The dosage depends on their

age and the water concentration, and then of

course, excessive fluoride is bad.

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Nursing Bottle Carries

# Nursing bottle carries are a common, severe form of

dental decay which may require expensive restorative

care.

# Prevention:

- Milk in bottle should never used as a pacifier at nap

or bedtime.

- Milk bottle feeding should be discontinued after

first birthday.

- Juice should always be offered from cup.

Nursing-bottle caries is the other concern

where there is a three-month-old that needs

all this dental work. It’s a severe form of

dental decay. The prevention is: you don’t

let them sleep with bottles. Milk in a bottle

should never be used as a pacifier at nap or

bedtime. We try to discontinue it by the first

birthday. You should always offer juice

from a cup and not from a bottle.

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A 15 month old child makes sounds but

speaks no real words and points to objects

that he wants.

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Delayed Speech

## Differential Diagnosis of Delayed Speech

- Hearing deficit

- Mental retardation

- Autism

- Neurologic disorders of articulation

- Abnormal environment

- Developmental language disorder

# Expressive

# Receptive

Delayed speech. This is a different diagno-

sis when a child isn’t speaking.

If hearing loss is greater than 30 decibels,

the hearing frequency will interfere with

speech and language development. The

degree of communicative disorder is associ-

ated with how deaf they are and the time of

onset. And unequivocally, early intervention

helps. There’s lots of problems with chil-

dren who don’t hear that aren’t recognized.

The types of hearing loss are: conductive,

obviously that means the structure, and

neurosensory. That’s the nerves and brains.

And often they are mixed. The average age

at this time is still greater than 12 months.

It’s when children are supposed to be speak-

ing, people realize they are not speaking and

then we do testing.

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Hearing Loss

## Hearing loss of >30 dB, in the frequency region for

speech (500-4000 Hz), will interfere with speech and

language development.

# The degree of communicative disorder is associated

with degree of hearing impairment and time of onset.

# Early intervention reduces the degree of impairment.

# Types of Hearing Loss:

- Conductive. Caused by a structural abnormality

- Sensorineural. Caused by abnormal cochlea, nerves,

or brain

- Mixed

- Average age of diagnosis of hearing impairment is

>12 months.

Estimated Number of Infants Heating Impaired

Number Prevalence Total

born

No risk 3,600,000 3:1000 10,800

High risk 400,000 30:1000 12,000

Total 4 million 5.7:1000 22,800

Ref: Northern Audiology Today, v6n2,1994

Hearing loss. The prevalence is 3 per 1000,

but in high risk groups it is 10 times that.

But still, half of all children who are deaf

have no risk. So you can take a high risk

population and test them and follow them,

but you are going to miss half of all children

with hearing impairment. Now we can test

hearing at any age. There is no child that

you can’t do a hearing test on, even new-

borns.

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Evaluation for Hearing Loss

# Testing is available at all ages, even newborns.

# Types of Tests

- Auditory brainstem response

- Behavioral Techniques: Behavior observation,

visual reinforcement, play audiometry.

- Acoustic Immittance: Tympanometry, acoustic

reflex, static compliance.

# Limitations of Tests

- Mental age, neurologic status, cooperation, testor

environment

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Risk Indicators for Hearing Loss

# Risk Indicators for Hearing Loss in Newborns thru

Age 28 Days

- Family history of hereditary sensorineural loss

- Congenital infections

- Craniofacial anomalies

- Birth weight < 1500 gm

- Hyperbilirubinemia

- Ototoxic drugs

- Low APGAR scores (#4 at one minute or #6 at five

minute testing)

- Mechanical ventilation > 5 days

- Stigmata of syndrome with hearing loss

# Risk Indicators for Hearing Loss Age 1 Month to 2

Years

- Parent concern over developmental delay

- History of bacterial meningitis

- History of head trauma with LOC or fractures

- Stigmata of syndrome with hearing loss

- Ototoxic medication use

- Recurrent acute otitis media or persistent otitis

media with effusion > 3 moths

Risk factors for hearing impairment include

family history of neurosensory loss, congen-

ital infections, craniofacial anomalies, low

birth weight, hyperbilirubinemia, ototoxic

drugs, meningitis, low Apgar, and treatment

with a ventilator. Hearing should be evalu-

ated anytime parents are concerned about

lack of language or that developmental de-

lay. Did they have meningitis? Major head

trauma? Stigmata of syndrome of hearing

loss that was present at birth? Ototoxic

drugs and of course your recurrent otitis

media or chronic otitis media with effusion.

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Hearing Loss: Risk Indicators

# Serial audiology is required for patients with the fol-

lowing high risk indicators (repeat testing even if early

tests are normal):

- Family history of hearing loss

- Congenital infection

- Neurodegenerative diseases

- Recurrent or persistent otitis media

After two years of life you still need to

check some children, even if the early test is

normal. Some children should be serially

assessed. Those who have a family history

of deafness, those who have known congen-

ital infections, particularly CMV, the

neurodegenerative diseases and then of

course those children with bad ear infec-

tions.

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Should all infants be screened for

hearing loss?

# Universal screening for infant hearing is not beneficial

and not presently justified. Bess, Paradise. Peals

98,2,1994

The trend has been testing infants and there

is a controversy. Only 50% of children with

hearing impairment can be identified by

those risk factors. So in 1993 there was a

NIH consensus statement that said we

should have universal hearing screening.

And they suggested it in two stages of oto-

acoustic emission, which is a behavioral

thing and then those who fail that should

have a brain stem. There are two states that

have done universal hearing testing for a

year now, Hawaii and Rhode Island. It is

probably worthwhile to test and detect these

children’s hearing impairments early and

make a difference in their lives.

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References and Resources

Developmental Issues:

Atlas of Pediatric Physical Diagnosis, 2 edition. Zitellind

and David, ed., Mosby-Woffe Publishers, 1994.

Glascoe, Martin, Humphrey. Consumer Reports: A Com-

parative Review of Developmental Screening Tests.

Pediatrics, v.86, n.4, pp.547-54, 1990

Frankenburg WK, Dodcls J, Archer P, et al. The Denver

II: A Major Revision and Restandardization of the

Denver Developmental Screening Test. Pediatrics,

v.89, n. 1, pp.91-7, 1992

Speech/Hearing Loss

Coplan J. Normal Speech and Language Development:

An Overview. Feds in Review, V. 16, N3, March

1995

NIH consensus statement (V. 11, N. 1, March 1-3, 1993)

"Early Identification of Hearing Impairment in Infants

and Young Children". Office of Medical Applications

of Research, NIH, Bethesda Md.