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Fetus: An unborn child / product of conception with child-parts (rather than just placenta), between eight weeks after conception and the moment of live birth Neonate: A child in the first four weeks of life after birth. Infant: A child in the first year of life after birth. Infant mortality: For a population, how many of its people per 1000 live births die before their first birthday. Pre-term: Born before 37-38 weeks. Nowadays a child born at 22 weeks will almost certainly die in the first six months. A child born at 23 weeks might survive but will almost certainly be profoundly brain damaged. A child born at 25 weeks has about a 3/4 chance of making it to six months and a better-than-half chance of not having gross brain damage on ultrasound Post-term: Both after 42 weeks. Small for gestational age ("small for dates"): Below 10th percentile on the charts. The child did not grow properly in the uterus, and the organs will have extra problems once the child is born.... Chromosomal problems Congenital infections ("torch") [see the details in my pediatry infectious disease]Toxoplasmosis Other (syphilis, etc.) Rubella Cytomegalovirus Herpes (usually not an intra-uterine infection) Other congenital anomalies Infarcts Tumors The thrombophilias (clots in the spiral arteries and between the villi of the placenta):Cocaine ("crack babies") Tobacco Opiate abuse Alcoholism Toxemia and other hypertension Large for gestational age: Above 90th percentile on the charts. Think of maternal diabetes. Low birth weight: As it sounds; a mix of "small for gestational age" and "preterm". Caring for tiny babies is expensive, and the outcomes uncertain; statistics are hard to find, but . At school age, surviving low birth-weight children still show signs of damage in all health parameters except happiness Low birth weight: <2500 gm Very low birth weight: <1500 gm One third of infants that die are very low birth weight infants. Another third are low birth weight infants. The remaining third are of normal weight Although survival of low-birthweight kids has improved tremendously (thanks largely to surfactant administration), there has been no decrease in the numbers of these kids, and it remains closely linked to underclass status . Survivors often need expensive long-term care (lung failure, brain damage). *The Oregon Plan ranked extraordinary life support for very-low birth-weight Medicaid babies as the second-from-the-bottom on a list of "where does the health care dollar do the most life-enhancing good". Due to right-wing political pressure, the Bush administration decided (1992) that this constituted "discrimination against the handicapped", and the rest is history (Hastings Center Reports 22(6): 21, Nov.-Dec. 1992). Placental problems Placenta previa (i.e., a low-slung placenta overlying the os) Abruption (i.e., a big bleed between placenta and uterine wall) Cord problems Compression (around neck, breech delivery, etc., etc.) Other (poorly-understood) Toxemia Prolonged rupture of the membranes Chorioamnionitis In fatal cases, the pathologist looks for squamous cells in the alveoli, meconium staining of the skin, and hyaline membranes in the alveoli (rather than the terminal bronchioles), as well as evidence of the exact mechanism in the cord, placenta, or dead child. 
Aortic coarctation Check for absence of peripheral pulses Vitals (Normal Newborn): Pulse: 120 to 140 bpm Blood Pressure 60/30 mmHg Respiratory Rate 40-60 bpm Murmurs Usually transient Gallup Rhythms 
Split S2 is Normal Split S2 absent Aortic or pulmonic valvular atresia or stenosis Results in high pulmonary vascular resistance Umbilical vessels Normally composed of 2 arteries and 1 vein Single umbilical artery seen in 1% of newborns Associated with renal anomalies Obtain Renal ultrasoiund at 2 to 4 weeks Umbilical Hernia Usually closes by age 2 to 3 years Surgery indications Defect exceeds 3 cm Hernia persists beyond age 5 years Umbilical granuloma Apply silver nitrate or isopropyl alcohol Persistant Abdominal Distention Consider obstruction or Ascites Liver Usually palpable 2 cm below costal margin Kidneys Usually palpable Abnormal Masses Wilms tumor Neuroblastoma Renal vein thrombosis Back Midline defects Shallow sacral dimple is normal Anus patent and not ectopic Anal reflex Meconium passed within 48 hours of birth 
Extremities Polydactyly Syndactyly Single Palmar Crease Seen in 4% of normal babies Also seen in Down's Syndrome Bowing of legs is normal variation Positional deformities Should be easily replaced to normal position Rule out Clubfoot Congenital Hip Dislocation Assess with Ortolani test Clubfoot
Epidemiology
Often Bilateral
Hereditary
Etiology
Mild: secondary to intrauterine compression
Severe: anatomic deformity (e.g. abnormal talus)
Signs (3 components)
Heel varus (medial deviation)
Medial malleoli are further from each other
Sole deviates medially (soles face each other)
Medial foot concave
Lateral foot convex (kidney shape)
Foot inverted
Plantar flexion with inability to dorsiflex
Equinus of Ankle and forefoot
Associated deformity
Congenital dislocation of Hip
Spina bifida
Myotonic Dystrophy
Arthrogryposis
Management
Refer immediately for serial casts
Start in first week of life
Take advantage of neonatal ligamentous laxity
Manipulate foot before and between casts
Stretches contracted soft tissues
Serial Casts weekly for 6-8 weeks
Dennis-Browne Splines
Severe clubfoot requires surgery
Posteromedial release of heel cords
Major surgery in 50-75% cases
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Congenital Hip Dislocation [see also my pediatry surgery page]
 Epidemiology: Classic Congenital Hip Dislocation
Incidence
Hip instability at birth: 1%
Hip dysplasia in infants: 0.1 to 0.3%
Girls 9 times more often affected than boys
Usually unilateral, but bilateral is common
Pathophysiology
Femoral head dislocates from acetabulum
Types
Classic congenital Hip Dislocation
Teratologic congenital hip dislocation
Congenital Abduction Contracture of the hip
Associated Conditions
Congenital Torticollis
Breech Presentation in utero
First degree relative with hip dysplasia history
Clubfoot
Signs: Classic Congenital Hip Dislocation
Ortolani test
Hip Clunk felt on exam
Distinguish from a hip click
Galeazzi's Sign
Barlow's Test
Hip instability
Dislocation maneuvers
Thigh adduction
Thigh extension
Relocation maneuvers
Thigh flexion, then thigh abduction
Pelvis symmetric
Radiology
Dynamic Hip Ultrasound (infant under age 3 months)
Diagnostic for congenital Hip Dislocation
Hip XRay
Not diagnostic for Congenital Hip Dislocation
Femoral head not calcified under age 3 months
Diagnostic for Acetabular Dysplasia
Abnormal acetabular fossa will be seen
Course: Classic Congenital Hip Dislocation
Many unstable hips at birth stabilize by 5 days
Management: Classic Congenital Hip Dislocation
Management indicated for hip instability beyond 5 days
Pavlik Harness
Splints hips in flexed and abducted position
Casting
Early Orthopedic referral
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Ortolani test [more details coming up for this part]
Indications
Evaluation for Congenital Hip Dislocation
Pathophysiology
Femoral head displaced superiorly, posteriorly
Technique
Infant's legs placed in frogleg position
Place third finger on greater trochanter
Use thumb and index finger to hold knee
Attempt relocation of femoral head into acetabulum
Push upward with greater trochanter (away form bed)
Push toward bed and laterally with thumb at knee
Interpretation: Signs of Dislocation
Hip clunk felt
Occurs when femoral head relocates in acetabulum
Suggests Congenital Hip Dislocation
Hip click
Benign finding
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Cephalhematoma: Hemorrhage under the scalp ("subgaleal hematoma").Caput succedaneum: Edema of the scalp where the head was pressed against the opening cervix. Intracerebral hemorrhages from dural sinuses or brain substance. The most important birth injury. Devastating. 
The neonatal scalp is reflected at autopsy to reveal dark red blood beneath the galea aponeurotica (dense connective tissue of scalp) and over the cranium. This is subgaleal hemorrhage and it is fairly common during the birth process[from webpath] "Accidents" are the leading cause of death, outranking each category of disease by a substantial margin. Child abuse and neglect (apparently included among "other" in "Big Robbins") is an important killer among children. Again, the true prevalence is unknown and is controversial -- at least some are overlooked ("accidents" or "sudden infant death syndrome").long bone fxs (shaft & metaphyseal) rib fractures skull fractures subdural & subarachnoid hemorrhage cerebral edema visceral injury (esp. duodenum & pancreas) long bone fracture: shaft long bone fracture: metaphysis rib fracture: posterior, lateral vertebral compression fracture spinous process fracture sternum acromion the MOST common fracture in abuse (4x more common than metaph. fx) not specific for abuse . . . except in the very young (shaft fx, esp spiral, in an infant < 9 mos old is presumptive evidence of abuse w/o convincing & verifiable history) most common sites: femur, humerus 4 mos raises head 5-6 mos rolls over 8-9 mos sits alone 15 mos walks alone 18 mos climbs stairs 24 mos runs well 36 mos alternates feet up stirs SPECIFIC for abuse AKA "corner" and "bucket-handle" fractures most common at the knee (distal femur & proximal tibia), ankle (distal tibia), and proximal humerus planar fx thru most immature part of metaphysis (primary spongiosa) from acceleration / deceleration / shearing forces periosteum adheres tightly to epiphysis, less well to shaft shaking results in whiplash effect transmitted to long bones; fx occurs thru weakest part of whiplashed bone (primary spongiosa) child may be held around chest & shaken violently, with limbs & head flailing (hence the whiplash injury) child may be held by limb(s) and shaken, applying more direct torsional & shearing forces to the limbs used as "handles" microfracture thru primary spongiosa thicker collar of metaphyseal bone at periphery periosteum usually normal except with extensive injury subtlest radiographic finding: metaphyseal lucency (non-specific, seen in leukemia) "corner" fracture and "bucket-handle" fracture are 2 different projections of the same metaphyseal fx appearance depends on shape of metaphysis itself & projection of fx callus unusual - difficult to date heal quickly (10 days to several wks) prompt radiography is ESSENTIAL the younger the infant, the quicker the healing usually no deformity or sequela except in the unusual caseof a hip metaphyseal fracture (may cause coxa vara) posterior fracture: virtually diagnostic of abuse occurs with chest compression during violentshaking (AP compressive force) seen in 5 - 27% of abused children 90% of rib fractures are in children < 2 yrs old rib is levered over costotransverse articulation results in fx near this site - most pronounced at ventral cortex lateral rib fractures may also occur this way and indicate abuse (AP compression) rarely if ever seen after CPR in normally mineralized bones of infants & young children1 leading cause morbidity & mortality mechanisms: shaking direct blow strangulation / suffocation chronic repetitive injury shaking alone is sufficient to cause fatal CNS injury (shearing / torsional forces) edema - most common, non-specific as to mech. (blow, strangulation, etc) shear injury at grey-white junction and in large WM tracks (c. callosum) cortical contusion, laceration SAH & SDH (when interhemispheric, are very worrisome for abuseblood adjacent to falx, usually asymmetric & posterior diff. to distinguish SAH & SDH here from violent shaking: hemispheres impact falx, on rebound bridging veins to superior sagital sinus are torn may get convexity hematomas similarly (also from direct blow) diffuse cerebral edema hemispheres of diffuse, homogeneous low attenuation, CSF spaces & grey-white jxn obliterated brainstem, cerebellum, & thalami retain normal attenuation so appear bright dismal prognosis hemispheres: edema & neuronal necrosis, leading to cystic encephalomalacia and/or atrophy thal, brainstem, cerebellum: increased density may be due to neovascularity neuronal preservation mineralized neurons petechial hemorrhages not specific for abuse may be seen in: drowning non-abusive head trauma when abuse-related, may be from: direct brain injury strangulation venous pressure from chest compression post-traumatic apnea CT
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MRI
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acute
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delayed presentation
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polytrauma
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differing ages of injuries, blood collections
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normal or equivocal CT with high suspicion (better than Ct for shear)
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sequela
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overall, poorly corr. with CNS injury (linear fx most common in NAT) non-specific (altho common) unless: stellate / eggshell crosses sutures multiple and / or bilateral occipital (implies significant force) inconsistent history ("rolled off changing table") 1% incidence skull fx in falls from 150 cm - much higher than a changing table, sofa, bed, or most parent's arms no significant underlying brain injury in these uncommon accidental skull fractures may be seen with: birth (in 14% of newborns, usu. gone by 5 days, always gone by 4 weeks of life). Discharge physical from nursery should document presence/absence retinal hemorrhage shaking in abuse (overhwelmingly most common cause outside immediate neonatal period). Their presence alone warrants abuse evaluation! violent trauma (MVA) - unusual but reported predominantly in children > 2 years old usually blunt trauma (punch or kick to abdomen, rapid deceleration after being thrown) estimated to account for 20% of all abuse fatalities intramural hematoma duodenum / proximal jejunum most common abdominal injury 60% in jejunum, most near Lig of Treitz, usually on mesenteric side of bowel 30% in duodenum (lateral & inferior wall) 10% in ileum (mesenteric side) ? is bowel most tethered most vulnerable? pt presents with pain & vomiting mural, asymmetric mass on UGI coiled spring appearance of heaped up proximal mucosa probably compressed against spine with blunt trauma abuse is common cause pancreatitis (trauma is overall most common cause in children) may develop pseudocyst widened C loop of duodenum spiculated duodenal mucosa sentinal loop colon cutoff sign (transverse colon) decreased pancreatic echogenicity at US, ductal dilation peripancreatic inflammation liver: contusion, laceration kidney: contusion, laceration, fx bladder: rupture adrenal: hemorrhage birth trauma: clavicle & humerus fxs normal variant: periosteal new bone in infants 2-8 mos of life (single layer, smooth, bilaterally symmetric) osteogenesis imperfecta: fxs, periosteal rxn (should also see osteopenia, +/- wormian bones, blue sclera) rickets: metaphyseal irregularity (look for osteopenia, wide physes) scurvy: white metaphyseal line of Frankel with sub-met lucency, spurs, periostitis (look for osteopenia, Wimberger ring around epiphyses) Vit A intoxication: periosteal rxn (look for normal metaphyses, no fxs, pronounced periostitis in ulnae & tubular bones hands & feet) Caffey's: periostitis mandible, clavicle, ulna (characteristic sites, no fxs, child < 6 mos old) syphilis: metaphyseal lucency, periostitis (destructive metaphyseal lesions - not fxs, + serology) leukemia: metaphyseal lucency (see lucent bands diffusely, osteopenia) Menke's kinky hair: metaphyseal spurring, flared anterior rib ends (no true metaphyseal fx, findings bilateral & symmetric, characteristic hair) remember to consider: congenital insensitivity to pain spinal dysraphism we as radiologists are uniquely able to diagnose abuse we may be the 1st to recognize abuse radiographic findings in abuse are among the most specific & diagnostic in medicine our findings may be pivotal to investigation & prosecution Birth defects cause death in abound 1 in 500 kids. Anencephaly Other neural tube defects: craniorachischisis spina bifida meningocele myelomeningocele Fetal alcohol syndrome TORCH complex (Toxoplasmosis, Rubella, CMV, Herpesviruses)Reciprocal translocations Robertsonian translocations Chromosomal deletions Chromosomal inversions Ring chromosomes Isochromosomes Important terminology: Haploid Diploid Euploid Polyploid Aneuploid Monosomy Trisomy Mosaicism Nondisjunction Trisomy 21 (Down Syndrome) Pathology and clinical features: mental retardation cardiac abnormalities skeletal abnormalities GI tract immune system disorders hematologic disorders neurologic disorders Down facies Trisomy 18 Trisomy 13 Facies Polydactly Deletion 5p- Deletion 11p- WAGR syndrome Deletion 13q- Prader-Willi/Angelman Klinefelter syndrome (47,XXY) Image HistologyTurner syndrome (45, X)Turner facies Turner syndrome, Streak gonads Turner syndrome, fetal hydrops Turner syndrome, cystic hygroma Fragile X Important terms: mendelian trait autosomal gene sex-linked gene dominant phenotypic trait recessive phenotypic trait codominance types of mutations point mutation missense mutation (an example of a point mutation) - nonsense mutation frameshift mutation large deletion Autosomal Dominant Disorders: Marfan Syndrome Arachnodactly Aortic dissection Floppy mitral valve Ehlers-Danlos Syndromes Osteogenesis Imperfecta NeurofibromatosesNF1, von Recklinghausen Disease NF2 central neurofibromatosis Achondroplastic Dwarfism Familial Hypercholesterolemia Autosomal Recessive Disorders: Cystic Fibrosis Molecular mechanism I Molecular mechanism II Lung, gross Pancreas, histology Lysosomal Storage Diseases: Gaucher disease Splenomegaly Spleen, micro Gaucher cells Tay-Sachs disease Niemann-Pick Lipidoses Mucopolysaccharidoses Glycogenoses (Von Gierke Disease, Pompe Disease, McArdle Disease) Inborn Errors of Amino Acid Metabolism Phenylketonuria Alcaptonuria (Ochronosis) Albinism X-Linked Disorders X-Linked Dominant TraitsX-Linked Recessive Traits Muscular Dystrophy (Duchenne-Becker MD)Hemophilia (Factor VIII deficiency) Fragile X Syndrome Cleft Lip and Cleft Palate Prematurity and Intrauterine Growth Retardation Organ Immaturity (Lungs, Liver, Brain) Respiratory Distress Syndrome of the Newborn (Hyaline Membrane Disease) Erythroblastosis Fetalis and Neonatal Hemolytic Anemia Birth Injury Sudden Infant Death Syndrome Benign tumors and tumor-like conditions (Hamartomas, Hemangiomas, Lymphangiomas, Sacrococcygeal Teratomas) Malignant tumors Leukemia Neuroblastomas Wilms tumor Retinoblastoma Gastrointestinal Illnesses Common Pediatric Illnesses 
Meningitis Respiratory Illnesses Skin Infections / Illnesses with Rash Mouth / Throat Infections Gastrointestinal Illnesses Viral Gastroenteritis Bacterial Gastroenteritis Giardia (a parasite) Hepatitis A Pinworms Common Pediatric Illnesses Ear Infection (Otitis Media) / Sinusitis Fever Pinkeye Meningitis H. flu type b (Hib) Meningococcal (N. meningitidis) Pneumococcal (S. pneumoniae) Viral Meningitis (Enterovirus) Respiratory Illnesses Mumps Common Cold Croup Influenza Whooping Cough (Pertussis) Pneumonia, Bronchiolitis, Bronchitis Tuberculosis (TB) Skin Infections / Illnesses with Rash Chickenpox (Varicella) Fifth Disease (Parvovirus) German Measles (Rubella) Hand, Foot and Mouth Disease (Coxsackievirus) Head Lice Impetigo (Staphylococcus or Streptococcus) Measles (Rubeola) Ringworm on body (Tinea Corporis) Ringworm on scalp (Tinea Capitis) Roseola (Exanthem Subitum, Sixth Disease) Scabies Poison Ivy Mouth / Throat Infections Diphtheria Cold Sore (Herpes simplex) Mononucleosis (Mono or Epstein-Barr virus infection) Strep Throat (Group A Streptococcus) Thrush (Fungal mouth infection) Wt > 10 kg - nebulise 5 mls Adrenaline 1:1000 Wt < 10kg - nebulise 0.5ml/kg adrenaline 1:1000 (make volume up to 5 mls with saline, as required) single dose only. Vernix - a creamy-white, substance similar to cheese, that may cover the baby's body or may be found in the creases of the skin. Vernix is a protective covering for the fetus while in utero. It acts as a natural lotion and may be gently rubbed into the skin or removed with the first bath.Molded Head-due to the overlapping of the cranial bones during a vaginal birth. The baby's head may appear elongated (cone head shaped) for the first day or so and then becomes nice and round. Babies delivered by cesarean delivery may not have a molded head unless they entered the pelvis/birth canal.Puffy face - due to pressure of the cervix and the birth canal during a vaginal delivery. Usually the puffiness diminishes in the first day.Swollen scrotum/labia, breasts - babies received hormones from mom while in utero thus causing swelling. Female babies may even have a vaginal discharge that may be tinged with blood. The swelling should resolve within a week.Milia - tiny white, pimple-like spots found on the baby's face; typically on the nose, cheeks or chin. These are simply clogged glands or hair follicles and should be left alone. They usually disappear in a week or so.Lanugo Hair - fine, soft hair found on the face, shoulders, back or upper arm. This hair rubs off and can be found on clothing as well as bedding.Cyanotic Hands/Feet - the newborn's hands and feet may appear bluish due to poor circulation to the extremities. Remember to keep the newborn warm which will help improve the circulation to the hands and feet.Dry or Peeling Skin - due to the baby being exposed to water during the entire pregnancy and then exposed to air at birth. Avoid using lotions or oils to remedy the dryness as these may cause rashes on the newborn.Cradle Cap - dryness and peeling of the scalp of the newborn. Baby oil applied to the scalp may help. Avoid pouring baby shampoo directly on the scalp. Lather shampoo in your hands prior to application to the scalp. If cradle cap remains for six months or more, consult your pediatrician as you may need to use an anti-dandruff shampoo.Sucking Blister - often babies are born with a hard, callous-like spot on the upper lip if they sucked their finger in utero; or babies can develop these blisters from the friction associated with breastfeeding. These blisters should not be treated and will fall off on their own.Newborn Rash - a.k.a. erythema toxicum-a rash occurring in 30-70% of newborns and can be found on all areas of the body except the palms of the hands and soles of the feet. No treatment is necessary. Rash will disappear within a few days.Stork Bites - a.k.a. telangiectatic nevi-are pink spots found on the nape of the neck, nose, upper eyelids, or upper lip. They disappear usually within a year or two.Mongolian Spots - bluish, black areas; most commonly found on the back or buttocks. Mongolian spots are more common on dark-skinned babies. Spots usually fade within a year or so.Caput Succedaneum - pooling of tissue fluids within the skin of the scalp causing swelling which extends across suture lines of the baby's skull. Occurs as a result of sustained pressure of the baby's head on the cervix. Swelling relieves itself in three or four days.Cephalhematoma - pooling of blood between the skull and the periosteum which does not cross the suture lines of the baby's skull. May occur as a result of sustained pressure on the bony pelvis, a vacuum extraction delivery or a difficult forceps delivery. Usually appear significantly a couple of days after the delivery and may last for about three weeks. No treatment is necessary. Bruising - babies may have bruising due to pressure on the pelvic bones during delivery or due to the use of forceps
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