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The Scoring System











Heart rate


Below 100

Above 100




Good crying

Muscle tone


Some flexion of extremities

Active motion




Vigorous cry


Pale blue

Pink body, blue extremities

Completely Pink


An Apgar score is done in 1 and 5 minutes after delivery
Based on table above Apgar score is interpreted as follows:
                        0 – 3   = poor
                        4 – 6   = fair
                        7 – 10 = excellent



·    Apnea should NOT last longer than 15 seconds for neonates


  Caput Succedaneum

·    Will appear as a swelling that is soft and it crosses the midline of the head


 Cord Care

·    Do not give tub baths until cord falls off around 7 – 14 days, when it looks dark and dry.

·    Clean 2 – 3 times a day with each diaper change with a cotton swab or cotton ball.

·    Fold diapers below the cord to allow it to air dry.



·    Anterior fontanel may bulge when baby cries.



·    HEAD circumference - 32 - 36 cm.



·    Extrusion reflex (tongue moves outward when touched, disappears at 3 - 4 months.



·    Scarf sign – sign of preterm baby

·    Harlequin sign – normal for newborns where one half of the body blanches while the other half becomes redder and there is a clear line.

·    Cullen sign – sign of intra-abdominal bleeding

·    Trendelenburg sign – sign of hip dysplasia



·    Jitterniness could be a sign of seizure.



·    Diaper rashes - often caused by Candida Albicans


   SPICA care

·    A body cast from the abdomen all the way down to the knee

·    Check for bowel sounds to ensure that paralytic ileus is not occurring.



·    Solid food must be introduced one at a time and within 4 – 7 days between each new food.

·    Milk formulas - those that use enzymatic hydrolysis to break down casein protein is not

      recommended for infants with cows milk allergy. Fresh yogurt can be used for those with

      lactose intolerance but not for infants with cows milk allergy; soy and goats milk may have

      the same allergic effect as cows milk.

·    Do not use microwave in heating milk since it will create an uneven heating of the milk; creating parts of the milk to be hotter and cause burns on an infant


Phenylketonuria (PKU)

·    PKU must be performed on fresh heel blood NOT cord blood; retardation occurs before metabolites are found in urine; Maintain level at  2-8mg/dL; LOFENALAC is a good


·    PKU test is usually done 3 days old but before the 7th day; 3 days to give time for baby to ingest protein sources of phenylalanine.

·    For PKU patients, avoid sweeteners with aspartame.


 Stool and Urine

·    There should at least 6 – 10 wet diapers a day

·    Stool progression:

          1.    Meconium (thick and dark green)

          2.    Transitional (thin brown to green)

          3.    Breastfed infant (yellow gold, soft)

          4.    Formula fed (pale yellow, formed and pasty stools)


Umbilical Cord

·    Usually wait about 2 weeks after birth before putting baby in tub to allow for the umbilical cord to dry and fall off.  





Premie 32 weeks gestation

·    Will have head lag

·    Male will have scrotal rugae


Full term

·    Will have vernix caseosa, cheesy like coating found on most full term babies  

3 – 4 months

·         Weight has doubled

·         Posterior fontanelle has closed

·         Sleep may last 9 – 11 hours

·         At 4 months, the baby can rollover. So watch out for babies that are on dressing tables or beds without rails.


6 months

·         Weight has doubled

·         Teething has began

8 - 9 months

·         Anxiety with strangers

·         Can grasp

12 months

·         Weight has tripled

·         Disappearance of a lot of reflexes. See reflexes under New Born Assessment

·         Anterior fontanelle has closed


12 - 15 months

·         Can walk without help

18 months

·         Building 3-4 blocks of tower

·         Can have push-pull toys

18 - 24 months

·         Thumb sucking, which should not go beyond 4 yrs of age since it can cause dental Problems

·    Good sphincter control for toilet training  


24 months

·         2 – 3 word phrases

30 months (2 ½ years)

·         Jumping with two feet

·         All 20 primary teeth should be present


3 years

·         Can dress themselves usually with supervision

            May have achieved bladder reflex control though night time control may not be expected until age 5


4 – 6 years

·         Imaginary friends

·         Bed wetting (enurisis) may be over after age 4. Note: bedwetting is more common in boys.


4 years

·         Be able to say first and last names

5 years

·         Be able to dress without supervision



·         Can differentiate human voice from other types of speeches.

·         Into solitary play and object permanence

·         Trust versus Mistrust = having someone respond to the infants need on a consistent basis



·    Into associative play.


School age

·    Nutrition and sport related injuries are major concerns.

·    Into cooperative play and concrete operational thinking.



·    Autonomy versus guilt = So, allow to develop autonomy by offering finger foods that will not potentially cause choking such as hot dogs, grapes, raisins, baby carrots sticks.

·    Encourage parents to room in with the toddler.

·    Encourage parents to bring in familiar objects from home.

·    Into preoperational thinking.



1.    Oral Contraceptive

·    Use another oral contraceptive if a patient is put on an antibiotic, which can decrease the effectiveness of the contraceptive.

·    If missed, do not double the dose.  Just take the pill as soon as remembered and use another form of contraceptive.

·    Weight gain may occur.

·    Can increase glucose on a diabetic mother.


2.    Diaphragm

·    Good contraceptive choice for diabetic mother.

·    Should not be kept on for more than 8 hours.

·    Needs to be resized annually and if the individual gains weight.                                      

    3.     Rhythm Method

·    Depends on the patient’s regularity of menstrual cycle.





Post Partum / Development Topics

Acute Respiratory Distress Syndrome (ARDS)

·    To maintain airway for infants, put the infant in supine position and hyperextend to facilitate breathing.


Alcohol Withdrawal

·    Baby may experience jitteriness. Snugly wrapping the baby in a blanket is a way to prevent muscle irritability. No need to stimulate the infant.


Anorexia Nervosa (see Bulimia Nervosa to differentiate)

·    Distorted body image

·    Gaining weight is the first priority.

·    Pectus Carnatum or Pigeon Chest - sternum is visible; - is common in girls with Anorxia Nervosa.

·    Patients are usually not allowed to choose their own food since they will only choose food that they want to eat.

·    Make sure you observe the patient taking in food and stay with the patient to avoid any attempt of purging. 

·    Usually not roomed in alone to prevent any possible purging or doing activities that will make the individual loose weight.

·    Patient is ask to  avoid participating in extrenuous activities.

·    High risk for electrolyte imbalance especially K.



·    Usually engages in routine and can get upset when the routine is interrupted.


Biliary Atresia

·    In assessing the infant, one will see an abdominal distention and it will cause poor weight  gain and clay colored stools.




·    Do not confuse with bronchitis. This is the inflammation of the bronchioles.

·    Common in children and infants and is usually occurs in the winter time and is caused by the Respiratory Syncytial virus (RSV).



Bulimia Nervosa (see Anorexia Nervosa to differentiate)

·    Patient usually have normal weight but feels hopeless to correct the problem.

·    Dental caries is common since the teeth tends to erode from constant vomiting.

·    Hoarse voice barely audible can be a sign of tracheosesophageal fistula from esophageal

      tear; laryngitis is a danger sign.

·    An adolescent with scars on his/her knuckles may be a sign that the individual is purging food or is inducing vomit after eating.


Cardiac Problems

·    Every baby is born with ductus arteriosus, a passageway between the pulmonary artery and       the aorta that normally closes within a few hours of birth. Failure of the ductus to close is a common premature problem.

·    Septal (septum is the wall that separates the left and right sides of the heart) defect is the presence of a whole in the septum.


            Septal Defects

            1.         Atrial Septal Defect

·    Causes a the oxygen rich blood from the heart’s left side leaks to the right side. In essence, the “oxygen full” blood is then pumped back into the lungs.

·    Long term outlook is good since the hole can be closed.


            2.         Ventricular Septal Defect

·    Similar concept as the Atrial Septal Defect, but, would mean the heart will have to work harder to pump extra amount of blood.

·    This may also lead to higher pressure in the lungs since there’s more blood there. The child will tire easily.



            Three Common forms of Obstructions

·    An obstruction to the blood flow is either a narrowing or a complete block of flow of blood.

·    Children are at risk for infection, endocarditis.


            1.         Pulmonary Stenosis

·    Cyanosis will occur since the right ventricle will have to pump harder to let blood flow from the right ventricle to the lungs.

·    Usually relieved by catherization by balloon valvuloplasty (valve is stretched open with an inflated balloon).


            2.         Aortic Stenosis

·    Cyanosis can occur since since the narrowing will make it hard for the heart to pump oxygen full blood out to the aorta and to the body.

·    Surgery may improve stenosis, but valve may eventually have to be replaced with an artificial one.


            3.         Coartaction of the Aorta

·    The aorta, the main artery that carries blood from the heart to the entire body is narrowed or constricted.

·    Leads to high blood pressure and can lead to Congestive Heart Failure.

·    Surgery can remove the stenosed area or balloon angioplasty can be done.


            Other Heart Problem

            There are other heart problems that may occur but only one is mentioned below.


            1.         Tetralogy of Fallot

·    Definintely causes cyanosis since Four major components are occurring:

          a.         Ventricular septal defect

          b.         Stenosis of the pulmonary valve

          c.         Right ventricle is more muscular than normal

          d.         Aorta lies directly over the ventricular septal defect.

·    Most children will undergo open-heart surgery.



 Cerebral Palsy

·    Affects the muscle movements caused not by problems in the muscles or nerves but by abnormalities in the parts of the brain that control muscle movement.

·    Bacterial or viral encephalitis, head injury from vehicular accident, child abuse or fall – all these can cause cerebral palsy also

·    Most common muscle incoordination observed are:

                      ataxia (inability to perform voluntary movements)

                      spasticity (exaggerated reflexes)

                      walking wth one foot or dragging of leg

                      waling on toes

                      “scissored” gait

·    A child may have visual and auditory difficulties.

·    Allow rest periods to patient in order to relax muscles.

·    There is no cure but supportive treatments, medications and surgery may help individuals improve their motor skills and ability to communicate.


Chicken Pox

·    Acyclovir may be given to shorten the course of the chicken pox.

·    Varicella vaccine is given to prevent chicken pox.

·    VZIG Varicella-zoster immune globulin is given to those with chicken pox.

·    Periactin is given to help in the itching.


Choanal Atresia

·    Having blockage of the nares



·    Watch for signs of infection, apply petroleum gauze and be careful in doing diaper changes.

·    If Plastibell is used, let it fall by itself (about 8 days after circumcision).



Cleft Lip

·    Avoid giving pacifiers. 


Coartation of the Aorta (see Cardiac above)

·    Leads to low blood pressure in the lower extremities and bounding pulses in the upper extremities. Thus, watch for absent or diminished femoral pulse.

·    Absence of femoral pulse is a sign.


Coombs Test

·    To help determine antibodies against the RBC.



·    Patient is usually put in a high humidified tent to help liquefy secretions.

·    Do not put toys, such as teddy bears, that can soaked and become a source of infection.



Cystic Fibrosis

·    A disease of the exocrine glands thus a child’s sweat will be salty.

·    Sweat test is done. A result of a sweat chloride greater than 60/meq/L is positive result for sweat test. BUT the degree of the pulmonary involvement determines the prognosis of the disease.

·    Chloride and sodium are tested in the test BUT Pilocarpine iontophoresis is the substance used to stimulate the sweating.

·    An infant with this disease will exhibit meconium ileus.

·    Child may be prone to sinusitis and nasal polyps and need surgery

·    99% of the males with the disease are sterile because of the obstruction that occurs on the vas deferens.


Diaphragmatic Hernia

·         Abdominal contents are occupying the chest area, thus, the abdominal circumference is bigger than the chest and the breath sounds are diminished on one side.

·         Reposition the infant to allow the affected side to inflate.



·    For infants, best treated with oral fluids like Pedialyte and only to resume regular feeding after resolving the problem.


Down Syndrome

·    White flecks on the iris can be seen.

·    Has epicanthal folds, broad hands and palmar creases.


Ductus Arteriosus

·    A passageway between the pulmonary artery and the aorta that normally closes within a few hours of birth. Failure of the ductus to close is a common premature problem.

·    See Cardiac above.



·    Cut the nails regularly to prevent excessive scratching

·    Avoid bubble baths and soaps with perfumes to lessen irritation

·    Wash clothes with mild detergents and mild softeners to lessen irritation



·         A congenital malformation of the urinary tract where the opening is on the dorsal surface of the penis.

·         There should be NO circumcision since the foreskin can be used for repair.



·    Airway is an issue since the tongue can cause an obstruction. So, be prepared with tracheotomy.   

·    Watch for drooling, which means child can’t swallow own saliva



·    Given to a neonate to prevent blindness which can be caused from Neisseria gonorrheae


Fetal Alcohol 

·    Fetal Alcohol Syndrome – the baby will have depressed respiration, slit-eyed and low set of ears.

·    Fetal Alcohol withdrawal is seen in newborn if the baby is jittery and irritable



·    After birth, it should be at least 2 fingerbreaths below the umbilicus.

·    No decrease in size of funds may be a sign of infection. Uterus should return to pre-pregnant size after 6 weeks. 



A. Autosomal Dominant

·    If one parent is affected, children have a 50% chance of being affected

                        Example: Marfan Syndrome

B. Autosomal Recessive

·    If one parent is affected and the other is not a carrier, all of the offspring will not be affected but will carry the gene.

·    AND if one parent is affected and the other is a carrier, all offspring will have one

        in two chance of being affected.

                        Example: PKU and Sickle Cell



  • Mother has positive culture for vaginal secretions

As a prophylactic, a baby’s eyes upon delivery is given an antibiotic ointment

Hipa Cast

·    Use a disposable diaper at the opening to prevent soiling of the cast.


Hirschsprung Disease

·    Characterized by ribbon-like stools.



·    Measuring the head circumference and determining its growth is the most objective way to diagnose



·    A congenital malformation of the urinary tract where the urethra opens on ventral side of the penis or for females, the urethra opens in the vagina.

·    Infant should not be circumcised to use the foreskin for futures reconstruction.

·    After reconstruction, child should avoid any toys that require straddling, swimming, or any rough playing.




1.    Hepatitis B – first dose at birth to 2 months. Second dose 1 month after first dose. And third dose, at least 2 months after the second dose BUT not before 6 months of age.


·    For IPV - neomycin streptomycin allergies are contraindicated  NOTE streptomycin,

      kanamycin, neomycin gentamycin - all must be avoided for a patient with Myasthenia       

      Gravis since they all block neuromuscular transmission

·    IPV and DPT repeat doses at 2 and 4 months. Tetramune injection is the immunization

      medication of choice for DPT and H. Influenza.

·    Hepatitis B - repeat doses at 1 and six

·    Influenza vaccine – usually given in October or November in the US when the climate starts 

      to change to a colder one.

·    Varicella – one is contagious from 24hours before the onset of rashes until all the lesions

      have crusted.

·    Phenylketenuria (PKU) – test is called the Guthrie test. It is done on the third day when the

      baby has just enough time to have time to ingest enough protein. The test should be done

      on third day to prevent any seizures and mental retardation caused by PKU.




·    Characterized by currant jelly stools because it contains blood and mucous.


IV insertion and Injections

·    Better to put the IV on the scalp for INFANTs to enable caregivers to carry and hold the baby easily.

·    Injections on child should be given on vastus lateralis NOT the dorsogluteal nor

      Ventrogluteal muscles.


Kawasaki Disease

·    Inflammation of the vessels that might cause

·    Acute febrile disease in children marked by fever, rashes, lymphadenopathy, and inflammation of blood vessels, including late cardiac complications.

·    Patient may be treated with Benadryl, Ampicillin, and Interferon beta. BUT is MANAGED by large doses of aspirin.



·    Inspiratory Stridor and brassy cough



·    Color initially is rubra and small amount of bleeding is expected.

·    Color should change to serosa.

·    Any large clot or foul odor maybe signs failure of uterus to decrease and infection



Lumbar puncture (also called Spinal Tap)

·      A lumbar puncture, or spinal tap, is a procedure to collect cerebrospinal fluid to check for the presence of disease or injury. A spinal needle is inserted, usually between the 3rd and 4th lumbar vertebrae in the lower spine. When the needle is properly positioned in the subarachnoid space (space between the spinal cord and its covering, the meninges), pressures can be measured and fluid can be collected for testing. See picture below.


·    Meningitis

·    Best diagnosed by lumbar puncture (see Lumbar puncture) it is the inflammation of the membranes covering the brain the spinal cord.

·    Sometimes correlated with Cerebral Palsy, a neurological disorder.

·    Common causes are viral infections but bacterial infections require immediate attention. Some bacterial strains that cause meningitis are Streptococcus pneumoniea, Haemophilus influenza, Neisseria meningitides, Listeria monocytogenes.

·    Common symptoms are change in mental status, nausea, vomiting, fever and chills, photophobia, severe headache. Additional symptoms to watch out for babies are poor feeding and irritability, bulging fontanelles, stiffness, rapid breathing.  

·    Early prevention for children is immunization with:

                      a.    Haemophilus vaccine (HiB vaccine) – helps in prevention of one type of meningitis

                      b.    Pneumococcal vaccine – to prevent pneumococcal meningitis

·    See pictures below of physical demonstration of symptoms of meningitis  

                        a.     Brudzinski’s  Sign

                        b.     Kernig’s Sign



                      Brudzinski Sign

One of the physically demonstrable symptoms of meningitis is Brudzinski's sign. Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed.



                      Kernig Sign


  One of the physically demonstrable symptoms of meningitis is Kernig's sign. Severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degree


·    An opening in the spine. Keep it covered with gauze with Normal Saline.



·    Avoid contact sports



Mongolian spots

·    Common with Afro-Americans



·    Monitor for decelerations;   NOTE: Pitocin increase cervical effacement in pregnant mothers and therefore increase contractions.

·    Also used to control bleeding at post partum. Given post partum to help firm the uterus and lessen the chance of hemorrhage.

·    Can cause uterine hypertonicity.


 Plumbism (also called lead poisoning)

·    Eating lead containing part such as paint. 1976 was the year in the US when lead was banned on paint.

·    PICA



·    Associative play – common with preschoolers where share toys and interact with each other during play.

·    Cooperative play – common with kids who are of school age. They do activities that make them accomplish a common goal or activity.

·    Parallel play – when toddlers play right next to each and play with similar toys without  interaction.

·    Solitary play – common with infants. They play on their own.



·    Has muscle weakness. So, periods of rest is important


Pneumonia in Children

·    Cough is productive.

·    Bacterial Pneumonia – usually accompanied with fever

·    Viral Pneumonia – Rhinitis is often seen.


Osteogenesis Imperfecta

·    Congenital disease where baby has normal calcium and phosphorus levels but has a fragile bone. Be careful in moving the baby even when diapering.

·    Additional calcium intake will not benefit the baby

·    Sclera has a blue tinge, has brittle teeth, and fragile bones. 


Pyloric Stenosis

·    Characterized by Projectile Vomiting. 

·    Regurgitation of feedings.



·         Up to 20 pounds the baby should be in a car seat in a semireclining position.



·    Best examined by having the patient bend from waist down and trace the spine from top to bottom.

·    Use of Milwaukee brace is recommended for a curvatures >20 degrees. If less than 20 degress, no intervention may be necessary.



Shaken Baby Syndrome

·         Look for retinal hemorrhage as a major sign


Sickle Cell Disease

·    Keep the patient well hydrated to prevent dehydration.

·    Controlling pain is important. Extreme exercises can exacerbate the pain.

·    Warm compresses may help relieve the pain from vessel occlusion.

·    Oxygenation is needed

·    Sickle cell may not be detected in a newborn up until 6 months because of the presence of fetal hemoglogin.


Sudden Infant Death Syndrome (SIDS)

·    As a prevention, do not put baby in prone position.

·    Common to all kids who died with SIDS has pulmonary edema and intrathoricic hemorrhage.


Tay Sachs disease

·    Cherry red spots on the macula may be seen.


Tape Worms / Pin Worms

·    Eggs hatch in the upper intestine and mature in a couple of weeks. Females migrate out of the anus where eggs are laid and this causes sever itching for a child. Flashlight can be used to examine the anal area 2 -3 hours after sleep.

·    Best to put a tape on the perianal area of a child before going to bed. The tape enables the worms to cling to and be evaluated in the lab. No need to scrape. 

·    The whole family has to be treated to makes sure no eggs remain.



·    Constant swallowing of a child may indicate bleeding though drooling of blood-tinged saliva is normal. But, bright red oral secretions can mean active bleeding. 

·    Respiratory stridor is a bad sign of airway obstruction.

·    Trying not to swallow is normal but the child will probably have frequent swallowing.

·    A child may have a temperature.


Turners syndrome

·    Child exhibits low posterior hairline, webbed neck and short stature


Varicelle (Chicken Pox)

·    A virus treated with antiviral medications


Rubella Vaccine

·    Those allergic to eggs, dogs, rabbits, and chicken are probably allergic to the rubella       vaccine.


Wilms Tumor (also called Nephroblastoma)

·    Characterized with palpable mass over the flank.



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