HIGH DISK INFANT

• CARE OF AT-RISK / HIGH RISK / SICK INFANT
• Intussusception


  A medical condition in which a part of the intestine folds into the section next to it, typically involving the small bowel and less commonly the large bowel
• Intussusception occurs more commonly in children than adults, and in children, males are more often affected than females. The usual age of occurrence is six to eighteen months old
• Causes of intussusception in children

  • Certain infections
  • Diseases like cystic fibrosis
  • Intestinal polyps
• Diagnosis of intussusception


  In children, UTZ is preferred while in adults a CT scan is preferred
• Signs and symptoms of intussusception

  • Periodic abdominal pain
  • Nausea and vomiting (sometimes green in color from bile)
  • Abdominal bloating
  • Bloody stool
• Children, or those unable to communicate symptoms verbally, may cry, draw their knees up to their chest, or experience dyspnea (difficult or painful breathing) with paroxysms of pain
• In children, intussusception at the ileocecal junction accounts for 90 percent of all cases
• Treatment of intussusception


  Intussusception is an emergency requiring rapid treatment. Treatment in children is typically by an enema with surgery used if this is not successful. Dexamethasone may decrease the risk of another episode. In adults, surgical removal of the part of the bowel, is more often required
• Failure to Thrive (FTT)


  Indicates insufficient weight gain or inappropriate weight loss in children, usually defined in terms of weight, and can be evaluated either by a low weight for the child's age, or by a low rate of increase in the weight
• Causes of FTT


  • Endogenous (or "organic")
  • Exogenous (or "nonorganic")
  • Mixed
• Endogenous FTT


  Due to physical or mental issues with the child itself, including problems with the gastrointestinal system, cystic fibrosis, diarrhea, liver disease, anemia or iron deficiency, physical deformities, milk allergies, FAS, raised metabolism from parasites, asthma, infections, hyperthyroidism or congenital heart disease
• Exogenous FTT


  Caused by caregiver's actions, including physical inability to produce enough breastmilk, using only babies' cues to regulate breastfeeding, chronic food insecurity, lack of nutritional awareness, and other factors beyond the caregiver's control
• As many as 90% of failure to thrive cases are non-organic
• Mixed FTT


  A child who is not getting sufficient nutrition may act content so that caregivers do not offer feedings of sufficient frequency or volume, or a child with severe acid reflux who appears to be in pain while eating may make a caregiver hesitant to offer sufficient feedings
• Diagnosis of FTT


  • Patient history that includes diet history
  • Complete physical examination looking for abnormal breathing sounds, signs of specific vitamin and mineral deficiencies, and potential signs of child neglect or abuse
  • Workup through blood work, X-rays, or other tests
• Signs and symptoms of FTT

  • Failure to thrive occurs in children whose nutritional intake is insufficient for supporting normal growth and weight gain, typically present before two years of age
  • Parents may express concern about picky eating habits, poor weight gain, or smaller size compared to peers
  • Physicians may identify FTT during routine office visits when a child's growth parameters are not tracking appropriately on growth curves
  • Physical exam findings such as scaling skin, spoon-shaped nails, neuropathy, "wasting" (deceleration in stature >2 standard deviations from median weight-for-height), and "stunting" (drop of >2 standard deviations from the median height-for-age)
• Treatment of FTT


  Psychosocial interventions to encourage child to feed themselves and make mealtimes a positive, enjoyable experience. If an underlying condition is identified, treatment is directed towards that. Special care should be taken to avoid refeeding syndrome when initiating feeds in a malnourished patient
• Refeeding syndrome


  A potentially fatal shift in fluid and electrolytes in a malnourished person as they receive artificial refeeding, can occur whether receiving enteral or parenteral nutrition (TPN)
• Sudden Infant Death Syndrome (SIDS)


  The sudden death of an infant, usually under 1 year of age, which remains unexplained after a complete postmortem investigation, including an autopsy, examination of the death scene and review of the case history
• What SIDS is not

  • Caused by immunizations
  • Caused by external suffocation or overlaying
  • Contagious or Hereditary
  • Caused by allergy to cow's milk
  • Caused by lack of love
  • Caused by vomiting or choking
  • Child abuse
• What SIDS is


  • Major cause of death in infants after 1st month of life
  • Sudden & silent in an apparently healthy infant
  • Unpredictable & unpreventable
  • Quick death with no signs of suffering - usually during sleep
• Characteristics of SIDS


  • Usually occurs in colder months
  • Mothers younger than 20 years old
  • Babies of mothers who smoke during pregnancy or are exposed to second hand smoke
  • 60% male Vs 40% female
  • Premature or low birth weight
  • Upper respiratory infections, 60% in prior weeks
  • Occurs quickly and quietly during a period of presumed sleep
• External appearance of SIDS infant

  • Normal state of hydration & nutrition
  • Small amount of frothy fluid in or about mouth & nose
  • Vomitus present
  • Disfiguration/Unusual position - dependant blood pooling/pressure marks
• Internal appearances of SIDS infant (Autopsy)


  • Pulmonary congestion & edema
  • Intrathoracic petechiae 90% of time
  • Stomach contents in trachea
  • Microscopic inflammation in trachea
• Typical SIDS infant scenario: Almost always occurs during sleep or appearance of sleep, usually healthy prior to death, may have had a cold or recent physical stress, may have been place down for nap, found not breathing or appearing dead, parents not hearing signs of struggle
• Emergency response to SIDS

  Initiate resuscitation per EMS System Practice Parameters & Protocols, observe location of infant, presence of objects, unusual conditions like high room temperature or odors
• Baby Colic


  Episodes of crying for more than three hours a day, for more than three days a week, for three weeks in an otherwise healthy child between the ages of two weeks and four months, often occurring in the evening
• Fewer than 5% of infants who cry excessively turn out to have an underlying organic disease, and while previously believed to be related to gas pains, this does not appear to be the case
• Diagnosis of colic


  Colic is diagnosed after other potential causes of crying are excluded, typically via a history and physical exam, with tests such as X-rays or blood tests not usually needed
• Causes for concern in a crying baby

  • Elevated temperature
  • History of breathing problems
  • Child who is not appropriately gaining weight
• Persistently fussy babies with poor weight gain, vomiting more than 5 times a day, or other significant feeding problems should be evaluated for other illnesses
• Signs and symptoms of colic

  • Infants normally cry an average of just over two hours a day, with the duration peaking at six weeks
  • With colic, periods of crying most commonly happen in the evening and for no obvious reasons
  • Associated symptoms may include legs pulled up to the stomach, a flushed face, clenched hands, and a wrinkled brow
  • The cry is often high pitched (piercing)
• Treatment of colic


  Management is generally conservative and involves the reassurance of parents, with calming measures like swaddling, holding the baby, swinging, shushing, and breastfeeding, as well as eye contact, talking, and holding the infant
• Trisomy 21 / Down Syndrome (DS)


  A genetic disorder caused by the presence of all or part of a third copy of chromosome 21, typically associated with physical growth delays, mild to moderate intellectual disability, and characteristic facial features
• Cause of Down Syndrome

  Trisomy 21 is caused by a failure of the 21st chromosome to separate during egg or sperm development (nondisjunction), resulting in a sperm or egg cell with an extra copy of chromosome 21
• About 88% of cases of trisomy 21 result from nonseparation of the chromosomes in the mother, 8% from nonseparation in the father, and 3% after the egg and sperm have merged
• Diagnosis of Down Syndrome

  • Before birth: When screening tests predict a high risk, a more invasive diagnostic test (amniocentesis or chorionic villus sampling) is needed to confirm
  • After birth: The diagnosis can often be suspected based on the child's physical appearance
• Physical characteristics of Down Syndrome

  • Small chin
  • Slanted eyes
  • Poor muscle tone
  • Flat nasal bridge
  • Single crease of the palm
  • Protruding tongue due to a small mouth and relatively large tongue
  • Airway changes lead to obstructive sleep apnea in around half
• Chromosome 21


  Cell has 24 chromosomes