As discussed by Sir Renchi Cainglet of the PPRE Review Specialists
Pediarobics
Month
Milestone
01
Head lag is prominent
02
Posterior fontanel closes Social smile appears
03
Carried objects in hand towards the mouth
04
Lifts head/chest from prone; head lag is not present
05
Rolls over; risk for falls or injury
06
Sits with suuport
07
Sits without support
08
Sits without support
09
Crawls and creeps; the abdomen is on the floor for crawling, while off the floor for creeping.
10
Starts to stand
11
Cruises— assisting themselves into standing or walking while holding onto something such as a wall.
12
Walks with support
15
Walks without support
24
Jumps one level
36
Walks backwards
48
Button Buttons
60
Hand dominance— ability to tie shoelaces, throw and catch a ball, and left- or right-handedness
Developmental Markers
Infants:
Solitary play
Stranger anxiety, onset as early as six months and peaks around eight months.
Wean into solid foods by six months.
Aspiration risk is present during infancy during the oral phase of psychosexual development; they will bring any object they are able to hold to their mouths.
Dentition: six months onwards— lower central incisors (six months), upper central incisors (seven months), upper lateral incisors (nine months), lower lateral incisors (eleven months)
Toddlers:
Parallel play
Negativistic, the tendency to say “No” in order to exercise autonomy. Intervene by provision choices rather than requests that can be answered with “No”.
Throwing Tantrums: a result of the inability to express their frustration. Intervene by ignoring the behavior while maintaining safety.
Separation anxiety: an intense fear of abandonment with three distinct phases— (a) protesting manifested by crying, screaming, etc., (b) despair manifested by isolation, anorexia, and withdrawal, and (c) denial, manifested by the toddler ignoring the returning caregiver to “deny” their feelings of anxiety. Intervention to reduce anxiety involves not prolonging departure, the provision of security objects/blankets, and informing the child when the parent will arrive (making sure that the toddler understands).
Physiologic anorexia: distractions from exploration may result in physiologic anorexia
Push-pull toys
Autonomy vs. Shame and Doubt
Dentition: completion of deciduous teeth (20 teeth) by two and a half years old. This is the best time to begin dental visits.
Preschooler:
Associative play
Fears of Mutilation/Castration, and the Dark/Ghosts from magical thinking. They become aware of the reality of death.
Newborn Assessment
Anthropology
Parameter
Normal Range
Deviations
Birth Weight
2.5 - 4.0 kg
Low Birth Weight (<2.5 kg), Very Low Birth Weight (<1.5 kg), Small for Gestational Age (<10th percentile), Large for Gestational Age/Macrosomia (>90th percentile)
Birth Length
45 - 55 cm
Head Circumference
33 - 35 cm
Hydrocephaly, Microcephaly
Chest Circumference
31 - 33 cm
The chest circumference becomes larger than the head circumference >1 year old.
Birth weight doubles by six months of age, triples by twelve months of age, and quadruples by two years of age.
Birth length doubles by four years of age, and triples by thirteen years of age. Growth ends at around 21 years old because of the closure of the epiphyseal growth plates.
Skin Assessment
Mongolian Spots are bluish-grey spots at the buttocks or lower back. This is caused by an increased melanocyte count. This is common among asian newborns. These spots disappear by school-age, but remain for life in 10% of cases.
Talengiectasia Nevii (“Stork Bites”) are pink pale patches at the nape or forehead due to overstretched blood vessels under the skin and are not a cause of concern. This disappears by two years old.
Nevus Vasculosus (“Strawberry mark”) are masses that are red and raised with rough edges commonly found on the forehead. They are formed from clumped blood vessels and tissues forming a benign mass. These often disappear from seven to nine years of age.
Nevus Flammeus (“Port Wine Stain”) are red-purplish marks seen on the face due to abnormal formations of small blood vessels under the skin. The mark is appears as if the face was stained by wine. Uniquely, this mark does not usually disappear, with its color darkening as the individual grows older.
Erythema Toxicum Neonatorum: is a normal newborn rash that may appear all over the body with an unknown cause, but is associated with an increased eosinophil count. The rash disappears within weeks.
Milia (“Milk Spots”) are white pinpoint papules on the nose, chin, or cheeks due to immature, distended sebaceous glands. These also disappear within weeks.
Finding
Colloquialism
Cause
Disappearance
Mongolian Spots
-
Melanocytes
School-age
Talengiectasia Nevii
Stork Bite
Two years old
Nevus Vasculosis
Strawberry Mark
Seven to nine years old
Nevus Flammeus
Port Wine Stain
Does not disappear
Erythema Toxicum Neonatorum
Within weeks
Milia
Milk Spots
Within weeks
Head Assessment
Parameter
Anterior Fontanel
Posterior Fontanel
Shape
Diamond-shaped
Triangle-shaped
Normal Time of Closure
12 to 18 months
2 to 3 months
Alternative Nomenclature
Bregmatic Fontanel
Lambdoidal Fontanel
TODO: add image for comparison
Parameter
Caput Succadaneum
Cephalhematoma
Description
Edema of the scalp and soft-tissue swelling due to traumatic/prolonged delivery
Swelling caused by subperiosteal bleeding of the skull as a result of traumatic/prolonged delivery.
Onset
Present at birth
Not yet present at birth
Crossing of the Suture Line
Distinctly, the swelling of caput succadaneum will “cross” the suture line. It affects the scalp, so it is not limited by the suture line
A cephalhematoma does not cross the suture line
Resolution
Resolves within hours to days
Resolves within weeks to months
Interventions
No interventions are necessary
No interventions are necessary
Ear/Hearing Assessment
Appearance: the ears should be symmetrical and is structured with a firm cartilage with quick recoil.
In preterm newborns, ear recoil is slow; the ears, if folded, will take a few seconds to return to its original position.
In children with down syndrome (Trisomy 21), ears are low-set. Their position in relation to the eyes (normally at the same level) is low.
Retrolental Fibroplasia (Retinopathy of Prematurity): a complication of oxygenation therapy when high concentrations of oxygen is delivered to the infant (>40% O2). This may result in blindness. It is known as the retinopathy of prematurity (ROP) because premature babies often require oxygenation. In oxygen therapy, blood vessels in the eyes will begin to proliferate abnormally, which can result in blindness.
Mouth Assessment
Epstein Pearls are white glistening cysts at the upper palate that appear as “pearls”. These are due to trapped keratin and epithelial tissues forming a bump or cyst. This will disappear within weeks and are not a cause of concern.
Nose Assessment
Choanal Atresia: an abnormality manifested by mouth breathing in the newborn. Mouth breathing is always an abnormality. This is a developmental abnormality wherein the nasal passages do not form; a channel between the nasal cavity and the oral cavity (the choana), is blocked by bone and mucous membranes.
Nasal Flaring: enlargement of the nose, with potential redness. This is always a sign of any disorders in respiration as the body attempts to improve ventilation.
Chest Assessment
Witch Milk, the production of breastmilk by newborns (of either gender) as a result of exposure to maternal hormones, and disappears within weeks once hormonal levels return to normal.
Genitourinary Assessment
Voiding within 24 hours should occur within a newborn.
In females, an edematous labia/clitoris is normal in newborns.
In females, pseudo-menstruation may occur due to the withdrawal of maternal hormones that the newborn was exposed to in-utero. This also disappears within weeks once hormonal levels return to normal.
In males, the scrotum should have rugae. A smooth scrotum is commonly seen in premature newborns.
In males, the testicles should be palpable. If these are not palpable, cryptorchidism (undescended testicles) may be present and is an abnormal finding. If the testicles do not descent, spermatogenesis will not occur due to body heat resulting in sterility. This may also result in testicular cancer.
Risk factors for cryptorchidism includes prematurity and maternal caffeine intake during pregnancy.
In males, the meatus should be at the tip of the glans. This may be malformed to an area dorsal (above from a side-view) to the expected anatomical location, known as epispadias or ventral (below from a side-view) to the expected anatomical location, known as hypospadias.
If either disorder is present, circumcision is delayed as the corrective surgery for the disorder may utilize the excess skin for reconstruction.
Back Assessment
Spina Bifida: an abnormality of the spinal column where a segment of the spinal bone fails to close, leading to an outpouching of spinal contents, which may include nerves, spinal fluid, blood vessels, etc.
Spina Bifida Occulta: a “covert” form of the disorder where the outpouching is not evident, except through some skin dimpling or a tuft of hair. This form may allow the individual to live a normal life with no complications.
Spina Bifida Cystica: an “overt” form of the disorder where the outpouching forms a sac. Depending on the contents of the contents of the sac, it may be further classified as a meningocele or a myelomeningocele (contains spinal nervous contents). In the absence of nervous contents in a meningocele, no motor or sensory loss occurs. Functional loss occurs in a myelomeningocele due to the involvement of spinal nerves, potentially resulting in paraplegia/paraparesis and bowel/bladder problems.
A major risk factor for congenital spinal abnormalities are those mothers who are deficient in Vitamin B9 (Folate)/Folic Acid found in green leafy vegetables.
Hip Assessment
Developmental Hip Dysplasia: a misplacement of the femur from its normal anatomical position. This is tested with Allis/Galleazi/Ortolanis sign. This procedure lies the child supine, flexes the hips and knees, then abducts the knees. A distinct clicking sound is heard as the femoral head clicks back into place in contact with the acetabulum.
Cardiovascular Assessment
Coarctation of the Aorta: a malformation of the ascending aorta where a segment of the aorta constricts. This results in hypertension, bounding pulses, warmth, etc. in the upper body supplied by the branches of the ascending aorta, and hypotension, weak pulses, cool clammy skin, etc. of the lower body supplied by the descending aorta. This is a characteristic presentation of a coarctation of the aorta.
Increased upper body blood flow can result in epistaxis.
Treatment: resection and end-to-end anastomosis of the constricted section.