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.

Key Findings from

History No symptoms
Appropriate growth and development
(9-month visit)

Key Findings from Abdominal mass

Physical Exam Pallor
No lymphadenopathy
(9-month visit) No jaundice
 Neuroblastoma
Wilms' tumor
Differential Diagnosis Teratoma
Hepatic tumor
Hydronephrosis

CT scan: Retroperitoneal mass of

nonrenal origin, heterogeneous in
consistency
Key Findings from CBC with differential: Normocytic
Testing anemia
Bone-marrow aspiration: Small-cell
rosettes in bone marrow
Urine VMA/HVA: Elevated

Final Diagnosis Neuroblastoma

Case highlights: Students explore an approach to well-child care that includes dietary
counseling, anticipatory guidance, review of immunizations, and developmental/behavioral
surveillance and screening. Specific topics covered include normal growth, review of sleep
issues, formula feeding, and the 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. An example is the Parents
Evaluation of Developmental Status (PEDS) for children birth to 8 years
May take place routinely during well-child visit or at any patient encounter
where there are concerns.

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:
Infants should be placed, facing the rear, in the middle of the back seat, since
that is the most protected part of the automobile.
Children < 13 years should not sit in the front seat. The backseat is the safest
place.
Car seats for children are required by law in all 50 states. Proper use is
essential for optimum performance. The most effective car-seat restraint is a
five-point harness, consisting of two shoulder straps, a lap belt and a crotch
strap.

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.
Regular cows milk not given until age 12 months due to concern for 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

Sits without
support

Lifts head Sits with Puts feet in Stands

head mouth while holding on
Gross
steady supine
motor
Pulls
736
GB
U Rolls over No head lag to stand
when pulled
to sit from
supine

Takes
2 cubes
Follows
Reaches

U Passes
Fine Follows to or
cube (transfers)
motor past midline Looks for
Grasps
dropped yarn
rattle Neat
pincer
grasp

Single
Cognitive, Laughs syllables
Vocalizes
linguistic, Turns to voice e.g.,
commun- Turns to Dada,
ication rattling Babbles mama
sound (nonspecific)
Feeds self

Works for toy Plays

Smiles pat-a-cake
responsively Feeds self
Waves
Personal- Smiles Regards Stranger bye-bye
social spontaneously own hand recognition
(prelude to Indicates
stranger wants
 anxiety)
Exhibits
stranger
anxiety

Physical exam:

Growth evaluation

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

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 intra-abdominal,
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. 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.

Chest x-ray: Can identify metastases to the chest.

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 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

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