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A. Fasim, M.A., M.D.

Deputy Director, Virginia Tech Carilion School of Medicine and Research Institute

The best results are obtained when blood from a clean venipuncture is allowed to drip directly into the tube from the needle or scalp vein set. Three-day-old full-term baby not receiving vitamin K has levels similar to a premature baby. It may be decreased in liver disease and consumptive states, and the usual functional assay is low in dysfibrinogenemia. D-Dimers are formed from the action of plasmin on the fibrin clot, generating derivatives of cross-linked fibrin containing pairs of D-domains from adjacent fibrinogen molecules. Normal levels depend on the type of assay used, which vary from hospital to hospital. False-positive D-dimers are common in the intensive care unit setting, because trivial clotting from catheter tips and other causes give positive results in this sensitive assay. Specific factor assays and von Willebrand panels for patients with positive family history can be measured in cord blood, or by venipuncture after birth. This test measures response to a standardized razor blade cut and does not predict surgical bleeding. Because functional platelet assays are best drawn through large bore needles, assessment later than the newborn period, or in affected family members, is preferable to testing neonates if possible. Although the treatment was successful in correcting the defect, no change in mortality was seen in comparison with controls (8). This will vary with the clinical situations, trend of the laboratory values, impending surgery, and so forth. An intravenous or intramuscular dose of 1 mg is administered in case the infant was not given vitamin K at birth. Infants receiving total parenteral nutrition and infants receiving antibiotics for more than 2 weeks should be given at least 0. If no new platelets are made or transfused, the platelet count will drop slowly over 3 to 5 days. If available, platelets from the mother or from a known platelet-compatible donor should be used if the infant has an alloimmune platelet disorder. If consumption coagulopathy is associated with thrombosis of large vessels and not with concurrent bleeding, heparinization without a bolus may be considered. Platelets and plasma are continued to be given after the heparin has been started. The infant may have been born in a busy delivery room, at home, or transferred from elsewhere. If the mother has been treated with phenytoin (Dilantin), primidone (Mysoline), methsuximide (Celontin), or phenobarbital, the infant may be vitamin K deficient and bleed during the first 24 hours. The usual dose of vitamin K1 (1 mg) should be given to the baby postpartum and repeated in 24 hours. Infants who are undergoing treatment with broad-spectrum antibiotics or infants with malabsorption (liver disease, cystic fibrosis) are at greater risk for hemorrhagic disease. Vitamin K1, 1 mg/week orally for the first 3 months of life, may prevent late hemologic disease of the newborn. Thrombin is the primary procoagulant protein, converting fibrinogen into a fibrin clot. The intrinsic and extrinsic pathways of the coagulation cascade result in formation of active thrombin from prothrombin. Plasmin is the primary fibrinolytic enzyme, degrading fibrin in a reaction that produces fibrin degradation products and D-dimers. In neonates, factors affecting blood flow, blood composition (leading to hypercoagulability), and vascular endothelial integrity can all contribute to thrombus formation. In utero, coagulation proteins are synthesized by the fetus and do not cross the placenta. Both thrombogenic and fibrinolytic pathways are altered in the neonate compared with the older child and adult, resulting in increased vulnerability to both hemorrhage and pathologic thrombosis. However, under normal physiologic conditions, the hemostatic system in premature and term newborns is in balance, and healthy neonates do not clinically demonstrate hypercoagulable or bleeding tendencies.

If untreated, late manifestations appear after 2 years of age and may include neurosyphilis, bony changes (frontal bossing, short maxilla, high palatal arch, Hutchinson teeth, saddle nose), interstitial keratitis, and sensorineural deafness, among others. The incidence of primary and secondary syphilis in the United States, which had increased significantly throughout the 1980s and early 1990s, underwent a dramatic decline to a historic low of 2. The incidence of syphilis is significantly higher in African Americans, in urban areas, and in the Southern United States. Along with the generally decreasing incidence of primary and secondary syphilis among women, the number of cases of congenital syphilis in the United States declined from a recent high of nearly 50 cases per 100,000 live births in 1995 to a low of 8. Paralleling the patterns of syphilis among women, congenital syphilis is substantially more common among infants of African American women (34. The most important risk factors for congenital syphilis are lack of prenatal health care and maternal illicit drug use, particularly cocaine. These tests measure antibodies directed against a cardiolipin-lecithincholesterol antigen from T. These antibodies give quantitative results, are helpful indicators of disease activity, and are useful for follow-up after treatment. A sustained fourfold decrease in titer of the nontreponemal test with treatment demonstrates adequate therapy; a similar increase after treatment suggests reinfection. Nontreponemal tests will be positive in approximately 75% of cases of primary syphilis, nearly 100% of cases of secondary syphilis, and 75% of cases of latent and tertiary syphilis. A notable cause of false-negative nontreponemal tests is the prozone phenomenon, a negative or weakly positive reaction that occurs with very high antibody concentrations. Although these tests are more specific than nontreponemal tests, they are also more expensive and labor-intensive and are therefore not used for screening. The treponemal tests correlate poorly with disease activity and usually remain positive for life, even after successful therapy, and therefore should not be used to assess treatment response. False-positive treponemal tests occur occasionally, particularly in other spirochetal diseases such as Lyme disease, yaws, pinta, leptospirosis, and ratbite fever; nontreponemal tests should be negative in these situations. New tests under investigation for the diagnosis of syphilis include the following: 1. Because IgM does not cross the placenta, a positive syphilis IgM test in newborn serum should indicate congenital syphilis. Late latent syphilis over 1-year duration or syphilis of unknown duration (without neurosyphilis). There are no proven alternatives to penicillin for the prevention of congenital syphilis. If an infected pregnant woman has a history of penicillin allergy, she may be skin-tested against the major and minor penicillin determinants. If these test results are negative, penicillin may be given under medical supervision. If the test results are positive or unavailable, the patient should be desensitized and then given penicillin. Desensitization should be done in consultation with an expert and in a facility where emergency treatment is available. The Jarisch-Herxheimer reaction-the occurrence of fever, chills, headache, myalgias, and exacerbation of cutaneous lesions-may occur after treatment of pregnant women for syphilis. Patients should be made aware of the possibility of such reactions, but concern about such complications should not delay treatment. If a mother is treated for syphilis in pregnancy, monthly follow-up should be provided. A sustained fourfold decrease in nontreponemal titer should be seen with successful treatment. Screening of newborn serum or cord blood in place of screening maternal blood is not recommended because of potential false-negative results. Any infant born to a mother with a reactive nontreponemal test confirmed by a treponemal test should be evaluated with the following: 1. This test should be performed on infant serum, not on cord blood, because of potential false-negative and false-positive results. The tests may be negative at birth if the infection was acquired late in pregnancy. Pathologic examination of the placenta or umbilical cord using specific fluorescent antitreponemal antibody staining, if available.

In some traditions, the health care team cleans and prepares the body, whereas, in others, family members prefer to complete this ritual. Religious/spiritual or cultural practices may include prayer, anointing, laying on of the hands, an exorcism ceremony to undo a curse, amulets, and other religious objects placed on the child or at the bedside. Decisions, rituals, and withholding of palliative or lifesaving procedures that could harm the child or are not in the best interests of the child should be addressed. Quality palliative care attends to this complexity and helps parents and families through the death of a child while honoring the familial, cultural, and spiritual values. The beliefs and values of what constitutes quality of life, when life ceases to be worth living, and religious/spiritual, cultural, and philosophical beliefs may differ between families and health care workers. The most important ethical principle is what is in the best interest of the child as determined through the process of shared decision making, informed permission/ consent from the parents, and assent from the child. Sensitive and meaningful communication with the family, in their own terms, is essential. The physician, patient, and family must negotiate the goals of continued medical treatment while recognizing the burdens and benefits of the medical intervention plan. There is no ethical or legal difference between withholding treatment and withdrawing treatment, although many parents and physicians see the latter as more challenging. Foregoing some measures does not preclude other measures being implemented, based on the needs and wishes of the patient and family. When there are serious differences among parents, children, and physicians on these matters, the physician may consult with the hospital ethics committee or, as a last resort, turn to the legal system by filing a report about potential abuse or neglect. These may change over time, and the use of open-ended questions to repeatedly assess these areas contributes to the end-of-life process. It is extremely difficult for parents to know when the burdens of continued Growth and Development David A. Although a somatic history and physical examination are important parts of each visit, many other issues are discussed, including nutrition, behavior, development, safety, and anticipatory guidance. Disorders of growth and development are often associated with chronic or severe illness or may be the only symptom of parental neglect or abuse. Although normal growth and development does not eliminate a serious or chronic illness, in general, it supports a judgment that a child is healthy except for acute, often benign, illnesses that do not affect growth and development. However, it is convenient to refer to growth as the increase in size and development as an increase in function of processes related to body and mind. Being familiar with normal patterns of growth and development allows those practitioners who care for children to recognize and manage abnormal variations. The genetic makeup and the physical, emotional, and social environment of the individual determine how a child grows and develops throughout childhood. One goal of pediatrics is to help each child achieve his or her individual potential through periodically monitoring and screening for the normal progression or abnormalities of growth and development. Growth is assessed by plotting accurate measurements on growth charts and comparing each set of measurements with previous measurements obtained at health visits. The body mass index is defined as body weight in kilograms divided by height in meters squared; it is used to classify adiposity and is recommended as a screening tool for children and adolescents to identify those overweight or at risk for being overweight (see Chapter 29). Normal growth patterns have spurts and plateaus, so some shifting on percentile graphs can be expected. Large shifts in percentiles warrant attention, as do large discrepancies in height, weight, and head circumference percentiles. When caloric intake is inadequate, the weight percentile falls first, then the height, and the head circumference is last. Caloric intake may be poor as a result of inadequate feeding or because the child is not receiving adequate attention and stimulation (nonorganic failure to thrive [see Chapter 21]).

Syndromes

• The burn is severe (third degree).
• Time it was swallowed
• Wound that breaks open or bulging tissue through the incision (incisional hernia)
• Feeling full after eating only a small amount
• Are pregnant
• Blurred vision
• Recessive traits need both genes in the gene pair to work together.
• Pap smear
• Keep the routine to a set amount of time each night. Give your child a warning when it is almost time for lights-out and sleep.

Breastfeeding or formula feeding should be maintained and not delayed for more than 24 hours. Enteral nutrition is always preferred because it is more physiologic, less expensive, and associated with fewer complications. Fewer complications are expected if at least some nutrition can be provided enterally. The lipid emulsion usually provides 30% to 40% of the required calories; it should not exceed 60%. The serum triglyceride concentration is monitored as the rate of lipid emulsion is increased, with reduction of the lipid emulsion rate if significant hypertriglyceridemia develops. This situation may be problematic in patients who cannot tolerate larger fluid volumes. Catheterrelated sepsis, most commonly due to coagulase-negative staphylococci, is common and, on occasion, necessitates catheter removal. Other potential pathogens are Staphylococcus aureus, gram-negative bacilli, and fungi. Electrolyte abnormalities, nutritional deficiencies, hyperglycemia, and complications from excessive protein intake (azotemia or hyperammonemia) can be detected with careful monitoring. The best preventive strategy is early use of the gastrointestinal tract, even if only trophic feeds are tolerated. Sodium is unique among electrolytes because water balance, not sodium balance, usually determines its concentration. Both of these mechanisms increase the water content of the body, and the sodium concentration returns to normal. In hyponatremia or hypernatremia, the underlying pathophysiology determines the urinary sodium concentration, not the serum sodium concentration. Pseudohyponatremia is a laboratory artifact that is present when the plasma contains high concentrations of protein or lipid. It does not occur when a direct ion-selective electrode determines the sodium concentration, a technique that is increasingly used in clinical laboratories. In true hyponatremia, the measured osmolality is low, whereas it is normal in pseudohyponatremia. Hyperosmolality, resulting from mannitol infusion or hyperglycemia, causes a low serum sodium concentration because water moves down its osmotic gradient from the intracellular space into the extracellular space, diluting the sodium concentration. For every 100 mg/dL increment of the serum glucose, the serum sodium decreases by 1. Because the manifestations of hyponatremia are due to the low plasma osmolality, patients with hyponatremia caused by hyperosmolality do not have symptoms of hyponatremia and do not require correction of hyponatremia. Patients with hyponatremia and no evidence of volume overload or volume depletion have euvolemic hyponatremia. These patients typically have an excess of total body water and a slight decrease in total body sodium. Some of these patients have an increase in weight, implying that they are volume overloaded. Nevertheless, they usually appear normal or have only subtle signs of fluid overload. Retention of water causes hyponatremia, and the expansion of the intravascular volume results in an increase in renal sodium excretion. Assessment of hyponatremia is a three-step process: (1) Determine if the osmolality is low; if yes, the patient has true hyponatremia. Infants can develop euvolemic hyponatremia as a result of excessive water consumption or inappropriately diluted formula. In hypervolemic hyponatremia, there is an excess of total body water and sodium, although the increase in water is greater than the increase in sodium. In renal failure, there is an inability to excrete sodium or water; the urine sodium may be low or high, depending on the cause of the renal insufficiency.