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Case 2
INFANT WELL CHILD (2, 6 AND 9 MONTHS) - ASIA
Author: Robin English, M.D., Louisiana State University, and Erin Knoebel, M.D., Mayo Medical College

Learning Objectives
1. Recognize appropriate growth patterns in infants up to 9 months of age using standard growth charts. 2. Know the nutritional requirements for appropriate growth for infants at ages 2, 6, and 9 months, including caloric requirements, differences between formula and breast milk, and how and when to add solid foods to the diet. 3. Recognize the difference between expected developmental milestones (surveillance) and standardized tools (screening). Use the Parents' Evaluation of Developmental Status (PEDS) or other screening test to evaluate the developmental milestones of the patient at 2, 6, and 9 months. 4. Recognize the importance of prevention and anticipatory guidance during the well visits, including behavior, development, safety and immunizations. 5. Develop a differential diagnosis for an asymptomatic abdominal mass and formulate a plan for evaluation. Summary of clinical scenario: This case is a longitudinal case following an African-American infant from her 2-month-old well-child visit through a 9-month-old examination. At the 9-month visit, the patient has an asymptomatic right-upper-quadrant (RUQ) abdominal mass. Diagnostic studies reveal the mass to be a retroperitoneal mass of nonrenal origin that is heterogeneous in consistency. Associated findings include normocytic anemia and small-cell rosettes in the bone marrow. The diagnosis of neuroblastoma is made and confirmed by the finding of elevated urinary catecholamine metabolites. Case highlights: Students explore an approach to well-child care that includes Key Findings from No symptoms dietary counseling, anticipatory guidance, review of immunizations, and History Appropriate growth and development developmental/behavioral surveillance and screening. Specific topics covered (9-month visit)growth, review of sleep issues, formula feeding, and the include normal

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assessment of normal infant development. At the 9-month visit, students work through the evaluation of an asymptomatic abdominal mass in the infant. Multimedia features include: Photos of an infant at 2, 6, and 9 months; abdominal X-ray and CT scan showing retroperitoneal mass; Technetium-99 bone scan showing tumor; bone-marrow slide showing small-cell rosettes.

Key Teaching Points

Knowledge
Components of a well-infant visit: Interval history Any illnesses or problems since the previous visit (if it is the initial visit, include a birth history [details of pregnancy and delivery: illness, medication, substance use, problems with delivery, prenatal labwork, results of newborn hearing screen]) Growth Head circumference, weight, and length/height Best assessed using a growth chart and analyzing the data over time Babies lose a little weight right after birth, but are expected to be back at a weight their birth weight by 2 weeks of age Average daily weight gain for a term infant is 2030 grams. Weight (approximation): Weight at 4 or 5 months=double birth weight Weight at 12 months=triple birth weight Length (approximation): Length at 48 months=double birth length Development At each well visit, physician should assess the four domains of development: Gross motor, fine motor, language/communication and social/behavior. If child is unable to achieve the milestones in one or any of the four areas at or near the appropriate age, then these areas are of concern for possible delay and further testing or evaluation should be done. Developmental surveillance: Comparing a child to expected behaviors by age Not as sensitive or specific as developmental screening using a validated tool Developmental screening: Assessment using an evidence-based developmental screening tool to pick up developmental or behavioral abnormalities. Examples: Parents Evaluation of Developmental Status (PEDS) for children birth to 8 years

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Ages and Stages Questionnaire (ASQ) Denver II The American Academy of Pediatrics (AAP) mandates developmental screening at the 9-month, 18-month, and 30-month (or 24-month) well child visits. Specific autism screening is recommended by AAP at 18 months and age 2 years. Many offices do developmental screening at every health maintenance visit, especially if the office takes care of children that have been medically underserved. These tests may involve parental reports and/or examination in the office. Diet Breastfeeding or taking formula (if formula, how is it being prepared) Vitamin D supplementation Quantity and timing of feeds Number of wet and soiled diapers per day Social history Who lives with child; who are childs caregivers Physical exam (see Skills below) Anticipatory guidance: A chance to help the parents anticipate child's development and nutritional needs and to advise them regarding child's safety. Topics may include: Child care Sleep patterns: To prevent sudden infant death syndrome (SIDS), infants must sleep on their backs. Most babies sleep through night by age 4 to 6 months. Infants at 6 months of age usually sleep through the night and take two naps during the day. Exposure to tobacco smoke Childproofing the home: Outlet covers, cabinet locks, stair barriers Safe storage of cleaning supplies and medicines Poison control number; place near phone Use of walkers: These are not recommended due to risk of injury, especially when there are stairs in home. Car seat safety: Children < 12 years should not sit in the front seat. The back seat is the safest place. Restraint recommendations: < 1 year and < 10 kg: Car seat, middle of back seat,

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facing rear > 1 year and > 10 kg: Car seat, middle of back seat, facing front > 4 years and > 18.2 kg (40 pounds): Booster seat, back seat, facing front > 8 years: Seat belt, back seat > 12 years: Seat belt, back or front seat Immunizations: Within the first five years of life, every child should receive the following vaccines (total number of each): DTaP: Diphtheria, tetanus, and acellular pertussis (5) IPV: Inactivated polio vaccine (4) Hib: Haemophilus influenza Type b (3 or 4, depending on manufacturer) PCV13: Pneumococcal conjugate vaccine, 13 serotypes (4) MMR: Measles, mumps, and rubella (2) Varicella (2) RotaV: Rotavirus (2 or 3, depending on manufacturer) HepA: Hepatitis A (2) HepB: Hepatitis B (3) Combination vaccines may be used instead of their equivalent component vaccines if licensed and indicated for the patients age, (e.g., Pediarixwhich combines the immunizations for DTaP, HepB, and IPVand Pentacelwhich combines the DTaP, IPV, and Hib). Annual influenza immunization recommendations: All children 6 months through 19 years of age Household contacts and out-of-home caregivers of children 0 to 59 months of age Children and adolescents in high-risk groups (e.g., asthma, lung or heart disorders, and immune deficiencies) are higher priority. Common immunization side effects: Fussiness and fever for 24 hours. If these persist for >24 hours, or more serious side effects, child should be seen right away. Infant nutrition: Until age 46 months, infants should be given only breast milk or formula. Plain water should not be given for hydration until infant is eating solid foods. Breast milk: Preferred source of nutrition Commercial formulas: Protein sources: Cow-milk protein, soy protein or hydrolyzed cows milk protein. Elemental formulas provide protein in the form of simple amino acids, and may also contain medium-chain triglyceride (MCT) oil for infants with absorption problems. Regular cows milk not given until age 12 months due to concern for

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colitis Formula types: Ready-to-feed (RTF) or those that require mixing prior to feeding (power or formula concentrate). Advise parents to follow package directions carefully when using powder or concentrate, and never to dilute formula. RTF: Given directly to infant from bottle without preparation Powder: 2 scoops powder mixed in 4 oz. (1/2 cup) water Concentrate: A 1:1 ratio of concentrate to water Caloric requirements of infant: Term infants: 100120 calories/kilogram(kg)/day Preterm infants: 115130 calories/kg/day Very low birth weight (VLBW) infants: Up to 150 calories/kg/day Breastfeeding infants need vitamin D supplementation (formula and milk are already supplemented). Most cost-effective method is with a multivitamin. Transition to solid foods: Typically occurs at ages 46 months (for infants born prematurely, use adjusted age): Many infants will not be ready for solid foods at 4 months. Signs that child is ready for solid foods: Able to sit up and keep head up on his/her own Can manipulate pureed foods like rice cereal in mouth (will not spit it out) Shows interest in solid foods (e.g., will open mouth and does not refuse spoon)Start by offering a small amount of iron-fortified infant rice cereal mixed with formula and watch how child accepts it, if at all. Each new food should be introduced only every five to seven days so that allergies can be identified. Feeding of 9-month-old infant:Requires 100 calories/kg/day, with approximately 75% of calories from breast milk or formula (i.e., 2428 oz per day) Can eat strained foods (Stage 2)which require more chewingand feed themselves with finger foods, such as toast, crackers, pasta, and banana. Meats, such as small pieces of chicken, may be started at this age. Discuss choking hazards with parents. Foods such as popcorn, grapes, hard candies, hot dogs, and jelly candies should never be offered at this age.

Skills
History: Developmental milestones: 2 months 4 months 6 months 9 months

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Sits without support Lifts head Gross motor Head up 45 Sits with head steady Rolls over Puts feet in mouth while supine No head lag when pulled to sit from supine Stands holding on Pulls to stand

Takes 2 cubes Follows 180 Grasps rattle Reaches Looks for dropped yarn Passes cube (transfers) Neat pincer grasp Single syllables e.g., Dada, mama (nonspecific) Feeds self Works for toy Smiles responsively PersonalRegards Smiles social own hand spontaneously Feeds self Stranger recognition (prelude to stranger anxiety) Plays pat-a-cake Waves bye-bye Indicates wants Exhibits stranger anxiety

Fine motor

Follows to or past midline

Cognitive, linguistic, Vocalizes communication

Laughs Turns to rattling sound

Turns to voice Babbles

Physical exam: Growth evaluation

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Head circumference: Measure circumference around widest portion of head, from occipital to frontal area. Weight Length General: Appearance, activity level, responsiveness Vital signs: Temperature Respiratory rate Heart rate Blood pressure Head, eyes, ears, nose, throat (HEENT): Anterior fontanelle: Measure and palpate Examine red reflex and sclerae: Red reflex is a red/orange color reflected from fundus through pupil when viewed through an ophthalmoscope from about 10 inches away. The red reflex is a substitute for a careful fundoscopic exam, since an infant will not hold gaze long enough to visualize the retina consistently. It gives direct information about the clarity of the eye structures. A red reflex should be elicited in all infants and children, beginning at birth. Failure to see a red reflex may indicate underlying abnormality (cataracts, glaucoma, retinoblastoma, or chorioretinitis). Nares: Patency, discharge Lips: Check color and hydration Tympanic membranes: Light reflex, mobility Neck: Suppleness, presence of mass Chest: Lungs: Listen for clarity, breath sounds, symmetry Heart: Rate, rhythm, murmurs Abdomen: Presence/absence of bowel sounds, masses, tenderness, softness, distension Lymphatics: Axillary, inguinal, cervical lymphadenopathy

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Hips: Ortolani and Barlow maneuvers Genitalia: Normal male/female genitalia Neurologic: Assess tone. Symmetry of muscle strength and range of motion Moro reflex present and symmetric: This reflex is elicited by an abrupt change in the infant's head position and consists of two parts: symmetric abduction and extension of the arms followed by adduction of the arms, sometimes with a cry. Reflex is present at birth and disappears by age 4 months. May be used to detect peripheral problems, such as congenital musculoskeletal abnormalities or neural plexus injuries. Toes upgoing bilaterally with Babinski maneuver Skin: Examine for rashes, turgor, jaundice, pallor, bruising, petechiae. Spine/back: Check for sacral dimple or hair tuft. Rectal exam: Not a routine part of infant physical exam, but should be done when intraabdominal, pelvic or perirectal process suspected. To perform exam in infant, lay infant supine. With one hand, hold feet and flex knees and hips on abdomen. Insert gloved and lubricated index finger of other hand into rectum. Palpate for hard stool and/or a mass.

Differential diagnosis
1. Neuroblastoma: Most frequently diagnosed neoplasm in infants (more than half of patients present before age 2 years). May present as a mass in the neck, chest, or abdomen. Children with an abdominal neuroblastoma may be asymptomatic or may appear chronically ill and have bone pain from metastases to the bone marrow or skeleton. Fever, pallor, and weight loss are frequent presenting symptoms. Arises from embryonal cell lines. Most cases of neuroblastoma are due to somatic mutations (arise in cells other than the gametes). In infants less than one year of age, these tumors may spontaneously regress. 2. Wilms' tumor: May present as an asymptomatic RUQ abdominal mass without lymphadenopathy or jaundice, growing and developing normally.

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Masses are generally smooth and rarely cross the midline. Associated symptoms occur in 50% of patients and include abdominal pain and/or vomiting; patients may also be hypertensive. Median age at diagnosis is 3 years. 3. Teratoma (germ cell tumor): A rare, malignant tumor that can present as a painless abdominal mass with no symptoms (i.e., no jaundice, pallor). As a rare cancer (which in itself is rare in children) it should be on the differential diagnosis even if quite low in the differential. If there are symptoms, they are usually related to pressure effects on neighboring structures and include abdominal or back pain, nausea, vomiting, constipation, and urinary tract symptoms. 4. Hepatic tumor: Although rare at this age, hepatoblastoma and benign liver tumors must also be considered in a young infant with asymptomatic RUQ abdominal mass. Jaundice may or may not be present. 5. Hydronephrosis: Obstruction at the uretero-pelvic junction can lead to hydronephrosis and a palpable kidney, which manifests sometimes as a flank mass. May be asymptomatic, although would usually present with a urinary tract infection.

Studies
Complete blood count (CBC) with differential: Use to identify anemia and also to look for cytopenia that may be associated with bone marrow infiltration; test is not specific for any one diagnosis. Urinary vanillylmandelic acid/homovanillic acid (VMA/HVA):Measures metabolites of catecholamines, which are elevated in neuroblastoma. This test is highly specific for neuroblastoma and can be 9095% sensitive in detecting neuroblastoma. Abdominal ultrasound:An abdominal ultrasound is the best choice for a first study because it can identify a mass, show the organ of origin, and determine if mass is solid, cystic, or combined. Purely cystic masses are less likely to be malignant. Abdominal computed tomography (CT) scan: A CT scan is best at revealing calcifications and shows the anatomy better than the ultrasound. The CT scan also allows evaluation of the lungs during the same study, which is important in finding metastases. Sometimes, if a lesion is purely cystic, a CT scan is not needed, which is why an ultrasound is done first. Skeletal survey (X-ray):Will identify metastases to the bone. Technetium-99 bone scan: The radionuclide bone scan is more accurate than either conventional radiographic studies or physical examination in localizing tumors. Bone marrow aspiration/biopsy: Bone marrow aspirations identify marrow

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involvement. Rosettes of small, uniform cells containing dense, hyperchromatic nuclei and scant cytoplasm (small-cell rosettes) in bone marrow are diagnostic for neuroblastoma.

Management
1. Referral to oncologist 2. Tumor staging 3. Family meeting with oncologist, nurse coordinator, and social worker to discuss prognosis and treatment options, care coordination 4. Resection versus observation of primary tumor and metastases 5. Long-term follow-up for recurrence Back to Top Copyright 2011 iInTIME. All Rights Reserved.

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