1. WELL CHILD CARE The Newborn Exam and General Pediatric Screening.
By Dr Chi Jokonya
2. General Rules Get a good FHx for congenital problems
Perinatal hx ie substance abuse
Examine each part of the baby
Develop a routine or system
3. Developmental Dysplasia of the Hip (DDH, formerly CHD) 1 in 100 unstable hip, only 1 in 1000 true dislocation.
Types: a) Typical normal child b) Teratological syndrome or abnormal bone
FHx (20%), firstborn, female (F:M 9:1), breech (40%)
Associations: congenital muscular torticollis; metatarsus adductus
4. DDH contd. Audible click means nothing.
Dx: highest yield at 1 month newborn screeing maybe ineffective and perhaps harmful.
Dynamic uss screen breech babies at 4wks
X-rays: AP and frog
Other: CT, MRI, arthrography
5. Treatment DDH Double/triple diaper for 2-3wks: probably ineffective in true DDH
Pavlik harness, Frejka splint, van Rosen splint 95% successful in dysplastic hips, 80% in DDH
Surgery at 6-12mths; cast and traction
3% recurrence
6. Fingers and Toes Extra digit: 2 in 1000 births, 30% FHx, usually 5th toe or finger: tie off EMLA or lidocaine anesthesia
Syndactyly: x-ray to be certain bones present. Think of syndrome (toes Smith-Lemli-Opitz)
Polydactyly: may need x-ray to preclude presence of bone in digit
7. Funny Looking Kids FAS
Downs/Edwards/Pataus trisomy syndromes
Cornelia de Lange
8. Umbilical Problems Single umbilical artery: 0.55% deliveries, 27% associated malformations.
Umbilical hernia: 35% African American babies, 4% white babies, increased in LBW. Association: trisomy 18, 21 and hypothyroidism. Usually close spontaneously if not surgery at 3 to 5yrs
9. Umbilical Problems contd Gastrochisis
Omphalocoele
Omphalitis
Umbilical granuloma rx with AgNO3
10. Birth Injuries Cephalohematoma
Brachial nerve injury: -90% Erbs palsy C5,C6,C7 -1% Klumpkes palsy C8,T1
Facial nerve palsy 0.5%, forceps/syndrome
Clavicular fracture may occur in utero
11. Nose Disorders Hemangioma
Choanal atresia
Cleft lip/palate/nose
Tilted, flattened or deviated -oligohydramnios: renal agenesis, Potters syndrome -think syndrome
12. Eyes NB Check red reflex!! - retinoblastoma
Cataracts: numerous causes. 50% missed at birth
Glaucoma: 50% primary infantile glaucoma, remainder familial so get FHx
13. Ears Low set many syndromes
Abnormal pinna: -large flabby urogenital malformations -flat pressed against head Potters syndrome -pits Beckwith Weidemann (BWS) -tags (BWS)
14. Screening in Pediatrics
15. When Should PE Be Done Birth 1mo, 6mo, 1yr
1, 2, 5, 10 and 14yrs
Both of above for screening purposes and neither conforms with recommendations of various primary care specialty groups.
16. The Physical Exam A composite of screens, most effective when purpose is health maintenance.
Yield of new abnormalities LOW
Hx defines most abnormal findings
NB need to be using BMI to identify obesity, chart and review growth curves.
17. Genetic and Metabolic Screens Newborn: PKU, tyrosinemia, galactosemia, hypothyroidsim, SCD.
Potential future screens: -CAH in boys, some states already doing -biotinidase deficiency (1 in 70 000) 9 states decided yes: cheap and easy to treat -cholesterol in late childhood and adolescence? Insufficient evidence
18. Tuberculin Testing PPD preferred (most standardized)
Low risk: screen at 12-15mths, before school and at 14-16yrs
High risk: screen annually
15mm always +ve, 10-14mm +ve in high risk gps, 5-9mm doubtful unless immunosuppressed.
19. Anemia Screen at 6 and 18mths
Hct more reliable than Hb
If positive MCV will distinguish IDA from thalassemia trait (smaller rbcs in TT)
20. Lead Poisoning Screen all children at 1yr?
All abnormal levels interview, educate, give questionnaire
Levels 10-14mcg/dl repeat in 1yr; 15-20mcg/dl repeat in 3mths; 20-30mcg/dl consider EDTA; >30mcg/dl requires intervention
www.ahrg.gov/clinic/uspstf/uspslead.htm
21. Scoliosis Late childhood/early adolescent mild types rarely progress and almost never cause significant disability.
Evidence show screening not cost effective and harm exceeds benefits.
Routine screening NOT recommended
www.ahrg.gov/clinic/uspstf/uspsaisc.htm
22. Urinalysis Screening NOT recommended: -proteinuria FP common: fever, exercise -orthostatic proteinuria transient and harmless -bacteria: non treatment of asymptomatic bacteruria does NOT increase freq of pyelo or cause renal insufficiency. Rx may INCREASE freq of pyelo
Screening NOT recommended but high index of suspicion in febrile illness
23. Auditory Screening 1 in 2000 severely hearing impaired
Healthy Newborns, screening safe insufficient evidence to recommend routine screening
Older children: gross assessment at all CV.
Test in kindergarten grades 1,3,5,7
Pure tone audimetry at 4yrs refer if fails to hear 2 frequencies at 25db (NB r/o OM)
24. Visual Screening During each health maintenance visit, <5yrs look for strabismus, ambylopia and as soon as possible visual acuity (USPSTF 2004)
Use fixation pattern in <3yrs. Cover one eye, encourage fixation. Child will not like having good eye covered.
School checks generally suffice in older children
25. Developmental Screening Must be in contesxt of H&P, vision and hearing screens.
Know normal developmental stages.
Major focus first year of life then preschool years.
Newer instruments such as ASQ (The Ages and Stages Questionnaires) are easier to use and more accurate than the DDST (Denver Developmental Screening Test) Journal of FP May 2006 Vol:55; No.5 415-421
26. Sickle Cell Conditions Screen at birth: HB electrophoresis
Imperative to start penicillin prophylaxis once diagnosis is made CT until 10yrs
2-16yrs transcranial doppler screening: inc BF >/=1 major blood vessel inc reisk of stroke, 2 +ve screens institute chronic transfusion therapy to keep HbS <30%
27. Gyn Screening Annual pap once sexually active
Routine chlamydia screen all sexually active adolescent females.
Testicular cancer: USPSTF recommends against routine screening, however, encourage regular self examination and examine at every visit.
28. Short List Birth to 10yrs Ht, wt, BMI
BP
Vision (3-4yrs)
Hemoglobinopathy at birth
PKU, T4 and or TSH at birth
29. Short List 11 to 24yrs Ht, wt and BMI
BP
Pap test
Chlamydia screen (females >20yrs)
Rubella serology or vaccination
Assess for substance abuse
30. Case Scenarios Cases
Questions
Discussion Children are not little adults Know age specific milestones Monitor growth charts/BMI !
