Pediatrics 02: Infant female well-child visits (2, 6, and 9 months) User: Elizabeth Hernandez Email: Date: August 20, 2021 1:26AM

Learning Objectives

Interpret standard growth charts to determine appropriate growth patterns in infants Summarize 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 Compare and contrast developmental surveillance and developmental screening at well child visits Distinguish normal developmental milestones at 2, 4, 6, 9 and 12 months of age Integrate anticipatory guidance and parental education on topics such as behavior, development, nutrition, safety and immunizations during well child visits Create a differential diagnosis for asymptomatic abdominal mass in a child Propose a workup for an infant with an abdominal mass List the components of a pediatrics health care maintenance office visit. Describe expected weight changes in healthy infants in the first two weeks of life. Describe how to properly obtain and record measurements of growth. Explain how to elicit the Moro reflex and its value in the neurologic assessment of infants. Describe common facial rashes of early infancy. List normal primitive reflexes of infancy. List conditions associated with abnormal red reflex in infants. List normal developmental milestone at 9 and 12 months of age.


Components of a Well-Child Visit

Interval history

If this is the first visit, obtain a detailed birth history. Ask if there have been any illnesses or problems since the previous visit. Using the available medical records, review any visit notes, hospitalizations, lab results, and radiology reports since the last visit. Ask about persistence or resolution of any previously identified medical issues. Ask if there are any new concerns today.


Developmental surveillance is recommended at every well-child visit when a validated developmental screening tool is not used. Developmental surveillance may include eliciting parental concerns about development, reviewing a developmental history if available, direct observation of the child and identification of risk factors for developmental delays. The American Academy of Pediatrics (AAP) recommends developmental screening with a validated tool at the 9-month, 18- month, and 30-month visits. One of several validated developmental screening tools may be used (e.g., the Parents’ Evaluation of Developmental Status [PEDS], or Ages and Stages Questionnaire [ASQ]. Specific screening for autism spectrum disorder is recommended at the 18-month and 24-month visits.


Growth is best assessed using a standard growth chart and analyzing the growth trends for weight, height, and head circumference (in younger children) over time.

Diet history

Inquire about feeding practices: breastmilk or formula feeding (in infants), or types and frequency of solid food and drink (in older children), and any feeding difficulties the parent has noted.

Family history

A family health history should be obtained at the initial visit and updated yearly. Obtaining a family health history is an important component of the well-child visit that can provide information on genetic, behavioral, and environmental risk factors.

Social history

Ask who lives in the household, who the primary caretakers are, and who takes care of the child when the parents are at work or school. Also assess for environmental safety risks (e.g., smokers, guns in the home, lead exposure).

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Mothers should be screened for postpartum depression during infant well-child visits at the 1-month , 2-month , 4-month, and 6-month visits, as it can adversely affect the critical period of infant brain development.

Physical exam

Anticipatory guidance

Each visit includes anticipatory guidance, which is your chance to help the parents anticipate the child’s development and nutritional needs and to advise them regarding the child’s safety.

Immunizations and lab work

Age-specific recommended immunizations and screening labs are performed at the conclusion of the visit.

Nutrition Guidance

Breast milk

Breast milk is the preferred source of nutrition for most babies. Babies who are exclusively or partially breastfed should receive 400 international units of supplemental vitamin D daily beginning soon after birth. Formula-fed babies consuming less than 1 L of formula per day also need vitamin D supplementation. The American Academy of Pediatrics recommends exclusive breastfeeding until 6 months of age, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant. Medical contraindications to breastfeeding are rare.


Commercial formulas provide complete nutrition for those babies whose mothers are unable to or choose not to breastfeed. Available formulas include those made with any of:

Cow’s milk protein Soy protein Hydrolyzed cow’s milk protein

There are also specialized formulas that provide protein in the form of simple amino acids (the true elemental formulas). Preparing the formula

Ready-to-feed formula: As the name implies, the formula is ready to feed as is. Powder: For most formulas, the ratio is 2 oz water added for each scoop of powder. Formula concentrate: The ratio is one part concentrate to one part water.

There is no need to give an infant extra bottles containing water only, because formula or breast milk fulfills maintenance fluid requirements. Transition to regular cow’s milk

Infants should take breast milk or formula until 12 months of age. According to the American Academy of Pediatrics: Young infants cannot digest cow’s milk as completely or easily as they digest breast milk or formula. Cow’s milk contains high concentrations of protein and minerals, which can stress a newborn’s immature kidneys. Cow’s milk lacks iron, vitamin C, and other nutrients that infants need. Cow’s milk can irritate the lining of the stomach and intestine, leading to blood loss in the stool. Cow’s milk does not contain the optimal types of fat for growing infants.

Early Growth

Most babies lose some weight in the first days after birth, then may regain their birth weight as early as 1 week of age, but are usually expected to have regained their birth weight by 2 weeks of age.

Caloric Requirements of 1- to 2-Month-Olds

Term infants Infants born at > 37 weeks gestational age require 100 to 120 kcal/kg/day. Average daily weight gain for terminfants is 20 to 30 grams.

Preterm infants Infants born at < 37 weeks gestational age require 115 to 130 kcal/kg/day.

Very preterm infants Infants born at < 32 weeks gestational age require up to 150 kcal/kg/day.

The Red Reflex


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The red reflex is the red or orange color reflected from the fundus through the pupil when viewed through an ophthalmoscope approximately 10 inches from the patient. It gives direct information about the clarity of the eye structures and therefore is a substitute for a careful fundoscopic exam, since a 6-month-old will not hold his or her gaze long enough for the examiner to visualize the retina consistently. Examination of the red reflex should be performed in a darkened room. In infants with more darkly pigmented skin the reflex may appear more gray than red. This reflex should be elicited in all infants and children, beginning at birth. Absence of a symmetric red reflex or the presence of leukocoria (white pupil) may indicate underlying abnormalities, including:

Cataracts Glaucoma Retinoblastoma Chorioretinitis

When to Refer

A pediatric ophthalmologist should be consulted immediately if leukocoria, an abnormal or asymmetric red reflex, or signs of nonaccidental trauma are identified on physical examination.

Moro Reflex

This reflex is elicited by an abrupt change in the infant’s head position and consists of two parts: Symmetric abduction Extension of the arms followed by adduction of the arms, sometimes with a cry

The reflex is present at birth and disappears by age 4 months. The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries.

Infant Rashes

Neonatal acne and seborrheic dermatitis are two common rashes seen at this age. Both are benign and generally resolve over time.

Neonatal acne: More accurately referred to as neonatal cephalic pustulosis, it is not true acne but an inflammatory reaction most likely due to colonization with malassezia species of yeast. Inflammatory papules and pustules usually limited to the face and sometimes scalp are common. Photo of neonatal acne. Seborrheic dermatitis: Most commonly presents as yellowish, greasy scales over the scalp, often called “cradle cap.” But it can also present as erythematous plaques around ears, eyebrows, nasolabial folds, and skin folds of the neck, axillae, and diaper area. Photo of seborrheic dermatitis.

Primitive reflexes

Primitive reflexes can be used: To evaluate the integrity of the central nervous system To detect developmental delay To assess normal development

Abnormalities seen may include asymmetry, absence of appearance—or delay in disappearance—of reflexes. Primitive reflexes present at birth (in addition to the Moro) include: Moro Reflex

This reflex is elicited by an abrupt change in the infant’s head position and consists of two parts: Symmetric abduction Extension of the arms followed by adduction of the arms, sometimes with a cry. The reflex is present at birth and disappears by age 4 months. The Moro reflex may be used to detect peripheral problems such as congenital musculoskeletal abnormalities or neural plexus injuries.

Palmar Grasp

Infant grasps examiner’s finger placed in open palm and tightens grasp when finger withdrawn. This reflex must disappear before the infant can begin grasping objects voluntarily. This reflex persists until 2-3 months of age.

Plantar Grasp

Infant flexes toes downward when examiner presses on ball of foot. This reflex must disappear before the child begins to take steps.

Asymmetric Tonic Neck Reflex (Fencing Reflex)

When examiner turns head to one side, infant while supine assumes “fencing posture” extending the arm on the same side as the head is turned and bending the other arm at the elbow. This reflex is one of the first steps in hand/eye coordination and must disappear before the infant can reach for objects in or across the midline.

Babinski Response

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Infant dorsiflexes the big toe and fans the other toes when examiner strokes the lateral aspect of the foot’s plantar surface. This reflex is normal in children up to 2 years of age.

Developmental Surveillance and Screening

Evaluating a child’s development should always take place routinely during the well-child visit and at any other patient encounter if the examiner or parent has concerns, even during an acute visit or hospitalization. Developmental Surveillance

Checking milestones (comparing a child’s behaviors to expected behaviors by age) is known as developmental surveillance. Developmental surveillance generally includes assessment of milestones in four domains.

Gross motor Fine motor Communication/social Cognitive/adaptive

If the child is not capable of passing the milestones in any of the four areas at or near the appropriate age, then these areas are of concern for possible delay and should be followed up or further testing or evaluation should be done. Developmental Screening

Surveillance is not as sensitive or specific as using a validated developmental screening test to pick up true developmental or behavioral abnormalities. Screening with a validated tool is recommended at 9, 18, and 30 months of age. Specific screening for autism spectrum disorder with a validated tool is recommended at 18 and 24 months of age because these are critical periods of early social and language development. For more information on developmental screening, see the AAP’s Policy Statement and Aquifer’s tool for learning the milestones, which includes videos demonstrating expected milestones in all four domains at each recommended well-visit age (2 months, 4 months, 6 months) from birth to age 5.

Anticipatory Guidance at the 2-month Visit

Solid Foods

Babies are developmentally ready to begin spoon feeding pureed solid foods between 4 and 6 months of age. Vitamin D

The recommended allowance of vitamin D for children up to 12 months of age is 400 international units per day. While there is remarkable evidence on the nutritional superiority of breast milk, there has been a concern that the amount of vitamin D in breast milk is not adequate. Unless infants drink 32 ounces (one quart) of formula milk each day (which is supplemented with vitamin D), they may not receive enough vitamin D. All breastfeeding infants and all infants drinking less than a quart per day of formula should receive vitamin D supplementation. Infants who are breastfeeding should begin supplementation with liquid vitamin drops in the first few days of life.

More information on vitamin D: AAP Policy Statement on Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents. Child Care

Many parents appreciate receiving materials on choosing a child care center. Sleep

Most babies sleep through the night by age 4 to 6 months. To help prevent sudden infant death syndrome, the AAP recommends that, for the first year of life, babies should sleep on their backs in their cribs on a firm surface, without soft objects like bumper pads, comforters, or stuffed animals, ideally, in their parents’ room. More information on safe sleep: AAP Updated 2016 Recommendations for a Safe Infant Sleeping Environment


Family members who smoke should be advised to quit or, at the very least, should avoid smoking around the infant. Small objects and plastic bags should be kept away from the baby to avoid choking and suffocation. Do not drink hot liquids while holding the baby. Do not leave the infant alone on high places like the sofa or changing table. Always keep a hand on these squiggly babies!

Car Seat Safety

Children under age 13 years old should not sit in the front seat. Until at least age 2 years, children should face rearward and ideally as long as possible until they outgrow their rear facing carseat. The National Safety Transportation Board and the AAP stress that the back seat is the safest place in a vehicle for children.

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The middle of the back seat is the most protected part of the automobile. 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 in Childhood

These are the vaccines and the number of doses of each that children should receive through 6 years of age:

Disease Vaccine Diseasespread by Disease symptoms Disease complications


Varicella vaccine protects against chickenpox.

Air, direct contact

Rash, tiredness, headache, fever

Infected blisters, bleeding disorders, encephalitis (brain swelling), pneumonia (infection in the lungs)

Diphtheria DTaP vaccine protects against diphtheria.

Air, direct contact

Sore throat, mild fever, weakness, swollen glands in neck

Swelling of the heart muscle, heart failure, coma, paralysis, death


Hib vaccine prote4cts against Haemophilus influenzae type B

Air, direct contact

May be no symptoms unless bacteria enter the blood

Meningitis (infection of the covering around the brain and spinal cord), intellectual disability, epiglottitis (life- threatening infection that can block the windpipe and lead to a serious breathing problems), pneumonia (infection in the lungs), death

Hepatitis A HapA vaccine protects against hepatitis A.

Direct contact, contaminated food or water

May be no symptoms, fever, stomach pain, loss of appetite, fatigue, vomiting, jaundice (yellowing of skin and eyes), dark urine

Liver failure, arthralgia (joint pain), kidney, pancreatic and blood disorders

Hepatitis B

HepB vaccine protects against hepatitis B.

Contact with blood for body fluids

May be no symptoms, fever, headache, weakness, vomiting, jaundice (yellowing of skin and eyes), joint pain

Chronic liver infection, liver failure, liver cancer

Influenza (Flu) Flu vaccine protects against influenza

Air, direct contact

Fever, muscle pain, sore throat, cough, extreme fatigue

Pneumonia (infection in the lungs)

Measles MMR** vaccine protects against measles.

Air, direct contact

Rash, fever, cough, runny nose, pink eye

Encephalitis (brain swelling), pneumonia (infection in the lungs), death

Mumps MMR**vaccine protects against mumps.

Air, direct contact

Swollen salivary glands (under the jaw), fever, headache, tiredness, muscle pain

Meningitis (infection of the covering around the brain and spinal cord), encephalitis (brain swelling), inflammation of testicles or ovaries, deafness


DTaP* vaccine protects against pertussis (whooping cough).

Air, direct contact

Sever cough, runny nose, apnea (a pause in breathing in infants)

Pneumonia (infection in the lungs), death

Polio IPV vaccine protects against polio.

Air, direct contact, through the mouth

May be no symptoms, sore throat, fever, nausea, headache

Paralysis, death

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Pneumococcal PCV13 vaccine protects against pheumococcus

Air, direct contact

May be no symptoms, pneumonia (infection in the lungs)

Bacteremia (blood infections), meningitis (infection of the covering around the brain and spinal cord), death

Rotavirus RV vaccine protects against rotavirus.

Through the mouth Diarrhea, fever, vomiting Sever diarrhea, dehydration

Rubella MMR** vaccine protects against rubella.

Air, direct contact

Sometimes rash, fever, swollen lymph nodes

Very serious in pregnant women—can lead to miscarriage, stillbirth, premature delivery, birth defects

Tetanus DTaP* vaccine protects against tetanus.

Exposure through cuts in skin

Stiffness in neck and abdominal muscles, difficulty swallowing, muscle spasms, fever

Broken bones, breathing difficulty, death

(Adolescent immunizations are discussed in other relevant cases in Aquifer Pediatrics.) Seasonal Influenza

Routine annual influenza vaccination is recommended for all persons aged ≥6 months who do not have contraindications. Combination Vaccines

Combination vaccines represent one solution to the issue of increased numbers of injections during single clinic visits, and may be used instead of their equivalent component vaccines if licensed and indicated for the patient’s age. Examples of combination vaccines are Pediarix® (DTaP, Hep B, IPV) and Pentacel® (DTaP, IPV, Hib). Vaccine Adverse Events

Common side effects of immunizations include redness or swelling at the injection site, fussiness, and low-grade fever. Significant health problems that occur after immunization should be evaluated immediately and reported to the CDC’s national vaccine safety surveillance program, VAERS. The risks of adverse effects are far outweighed by the risks of serious consequences from contracting the diseases themselves, so the AAP recommends routine immunization of all healthy children.

Typical Early Childhood Growth Patterns

Most healthy infants will double their birth weight by 4 to 5 months and will triple their birth weight by 1 year of age. In addition, most children will reach double their birth length by age 4 years. Former preemies, small for gestational age babies, and others with chronic health issues do not always follow this pattern, and there are separate growth charts available for these special populations. In 2006, the World Health Organization (WHO) released a new international growth standard which reflects how infants and young children grow under optimal nutritional conditions. The WHO standards establish the growth of the breastfed infant as the norm and provide a better description of ideal, rather than typical, growth patterns. WHO Growth Standards Are Recommended for Use in the U.S. for Infants and Children 0 to 2 Years of Age.

6-Month Developmental Milestones

Gross motor

Rolls over supine to prone

Sits briefly unsupported

No head lag when pulled to sit from supine

Fine motor

Reaches for objects and transfers hand to hand

Looks for dropped itemss

Bangs small object on surface


Turns toward voice/begins to turn when name called

Babbles (i.e., use of repetitive consonants: ba-ba-ba or da-da-da) (When the child says da-da-da, the family reinforces the sounds by praising the infant; then the infant makes the connection of the sound to the father.)

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Social/Adaptive Feeds self/pats or smiles at reflection in mirror

Demonstrates stranger recognition, the prelude to stranger anxiety

Child-Proofing the Home

There are several steps parents or guardians should take to childproof their home – before children begin crawling and walking. You should also recommend that grandparents or any other care environments where the children spend significant time follow these steps. These include:

Installing electrical outlet covers Putting in cabinet locks Setting up stair barriers and Making sure cleaning supplies and medicines are safely stored out of reach of children.

In addition, the number for poison control should be kept near the phone. For a more comprehensive list of childproofing recommendations, visit Healthy

Anticipatory Guidance at the 6-month Visit

Car seat placement: The car seat should still be in the back seat, facing the rear. If the child grows out of their infant seat, parents should place a new convertible car seat still rear facing in the backseat of the car. Use of walkers: The AAP has recommended against the use of walkers because of the risk of injury, especially when there are stairs in the home. In addition, walkers do not teach children to walk any earlier than they otherwise would. Dietary changes:

New foods should be introduced one at a time. There are no restrictions to the types of food babies can get except we do not recommend honey or cow’s milk. There is no evidence that waiting to introduce allergy causing foods like eggs, soy, peanuts, dairy or fish after 4-6 months of age prevents food allergy. Babies do not need juice but can be offered sips of water from a sippy cup or straw with meals. To prevent choking, all solid foods should be soft and easy to swallow. Stooling patterns, colors, textures may change as new solid foods are introduced and are usually due to the baby’s still developing digestive tract and are normal changes.

Developmental changes:

6-month-olds may be resistant to being away from their primary caretaker for the next few months, but this “stranger anxiety” is normal. If not already begun, now is a great time to start reading books to the infant. Reach Out and Read is a nonprofit organization that gives young children a foundation for success by incorporating books into pediatric care starting at the 6-month well child visit. Learn more about the milestones of early literacy development. The 6-month-old should be expected to take two naps per day, and will probably sleep through the night.

The AAP’s website has much more information on anticipatory guidance and well-child care for parents and professionals.

Annual Review of the Immunization Schedule

Members of the Centers for Disease Control and Prevention, the American Academy of Pediatrics, and American Academy of Family Physicians meet annually to formulate an immunizations schedule that is as evidence-based as is possible. The current year’s immunization requirements are available from the CDC. As noted previously, combination vaccines such as Pediarix ® (DTaP, HBV, IPV) or Pentacel ® (DTaP, IPV, HiB) may be used to decrease the number of injections at a visit and facilitate administration of vaccines at the earliest possible date.

Acetaminophen and Vaccines

The use of antipyretics for the prevention of fevers associated with vaccine administration merits careful consideration. The prophylactic administration of acetaminophen has been associated with decreased antibody concentrations for some vaccine antigens, although all concentrations remained in the protective range.

12 Month Developmental Milestones

By the time a child is 12 months old, developmental milestones include: Gross motor: Stands alone (many can walk well). Fine motor: Has a well developed, “neat” pincer grasp. Language: Says “mama” and “dada” (specific to that person) and one or two other words. Social/adaptive: Hands parent a book to read, points when wants something, imitates activities and plays ball with examiner.

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Nine-month growth chart

Prognosis of Stage 4S Neuroblastoma

It seems paradoxical for a cancer that has metastasized to be considered a favorable stage. However, in infants less than 1 year of age, these tumors may spontaneously regress. This is due to the unique nature of this tumor derived from embryonal cell lines.

Genetics of Neuroblastoma


According to the most recent studies, there are familial forms of neuroblastoma, but these account for only about 1% of cases. The familial form appears to be autosomal dominant, with low penetrance.

Penetrance refers to the percent of individuals with a mutation that display the clinical effects of the mutation. The fact that the mutation causing familial neuroblastoma has low penetrance means that many people who inherit the mutation will not have neuroblastoma. For patients with a family history of neuroblastoma, genetic tests to determine if germline mutations in the PHOX2B or ALK genes are commonly done.

These pedigrees show examples of the autosomal dominant inheritance with complete and low penetrance:

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Examples of the autosomal dominant inheritance with complete and low penetrance Non-Familial

Most cases of neuroblastoma are due to somatic mutations. That is, these mutations arise in cells other than the gametes. Somatic mutations are not passed to the next generation.

Clinical Skills

Growth Parameters

Weight and Length

Review the weight and length as recorded, repeating any measurement that is concerning or seems inconsistent with previous growth patterns.

Head Circumference

Measure the circumference around the widest portion of the head, from the broadest part of the forehead to the occipital prominence at the back of the head.

Growth chart

Plot your measurements on the growth chart.

Introducing Difficult News

There are a number of acceptable ways to introduce a difficult topic such as a serious diagnosis to the family. Of course, as the family begins to understand the enormity of the diagnosis, they may not be ready to receive any more information. Some recommendations:

Delivering information in a direct but caring fashion can allow a family member to start processing bad news. Expect family members to react emotionally, and be prepared to respect and support their feelings. When the family is emotionally ready to hear more information, it is important to convey that treatment decisions need to be made urgently.


Initial Testing

Initial workup for abdominal mass

CBC with Differential

The CBC with differential is helpful in identifying the extent of anemia and to look for cytopenia that may be associated with bone marrow infiltration. This test is not specific for any one diagnosis.

Catecholamine Metabolites (VMA and HVA)

Urine or serum VMA/HVA measures metabolites of catecholamines, which are elevated in neuroblastoma. This test is highly specific for neuroblastoma and can be 90-95% sensitive in its detection.

Chest x-ray

A chest x-ray can identify metastases to the chest. Chest CT or MRI is necessary only if metastases are seen on x-ray.

Bone Scan

A bone scan can identify metastases to the bone and is more sensitive than a skeletal survey (plain radiographs) as part of © 2021 Aquifer, Inc. – Elizabeth Hernandez ( – 2021-08-19 21:26 EDT 9/12



a metastatic workup. Abdominal Ultrasound

An abdominal ultrasound will identify a mass, show the organ of origin, and determine if the mass is solid, cystic or combined. (Purely cystic masses are less likely to be malignant.) This is the best choice for a first imaging study. It can be done quickly and does not require coordination of sedation of the infant for the study.

Abdominal x-ray

A plain film can identify the presence of a mass, and perhaps whether it has calcifications, it cannot reveal other important information about the mass. This film may be more urgent if there is any evidence of bowel obstruction from the mass. The plain radiograph is not the best imaging study to order first.

Abdominal CT

A CT is best at revealing calcifications, and-importantly especially for a surgeon-shows the anatomy better than an ultrasound. It also reveals the consistency of the tumor. Allows evaluation of the lungs during the same study, which is important in finding metastases. If a lesion is purely cystic, a CT scan is not needed, which is why an ultrasound is done first.

Clinical Reasoning

Differential Diagnosis for RUQ Mass and Pallor in a 9-Month-Old Infant

Serious illnesses may cause a decrease in growth and even weight loss, but normal growth should not eliminate serious diagnoses from your differential.

Condition Discussion

Hepatic neoplasm

Although rare in children this age, an hepatic neoplasm (whether malignant, such as hepatoblastoma, or benign) can cause an asymptomatic abdominal tumor and must be considered in a young infant with an asymptomatic RUQ abdominal mass.

Jaundice may be a feature, but the lack of jaundice does not rule out this diagnosis.


An obstruction at the uretero-pelvic junction can lead to hydronephrosis and a palpable kidney, sometimes manifesting as a flank mass.

In the newborn, a multicystic kidney may cause such an obstruction.

While possibly asymptomatic, hydronephrosis causing a 6 cm palpable mass would usually present with a urinary tract infection.


The most frequently diagnosed neoplasm in infants; more than half of patients present before age 2.

The tumor may present as a painless mass in the neck, chest, or abdomen.

Children with an abdominal neuroblastoma may be asymptomatic; however, they may also appear chronically ill and may have bone pain from metastases to the bone marrow or skeleton.

Fever, pallor, and weight loss are frequent presenting symptoms.

Neuroblastoma is a likely diagnosis in an infant younger than a year of age who has an asymptomatic RUQ abdominal mass and pallor and no jaundice.


This is a rare malignant tumor.

A teratoma may present as a painless abdominal mass without other symptoms or it may cause pressure effects on neighboring structures resulting in abdominal or back pain, nausea, vomiting, constipation, and/or urinary tract symptoms.

A rare form of cancer (which in itself is rare in children), teratoma should be considered, even if it is quite low on the list.

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Wilms’ tumor (nephroblastoma)

This is a likely diagnosis in a child with an asymptomatic RUQ abdominal mass who has no lymphadenopathy or jaundice on exam and who is growing and developing normally.

These tumors are often discovered by the parents or on routine examination.

The 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.

The median age at diagnosis is 3 years.

Wilms’ tumor is commonly associated with Beckwith-Wiedemann syndrome, a genetic overgrowth syndrome. Other features that may be seen in children with this syndrome include omphalocele, hemihypertrophy, hypoglycemia, large for gestational age, and other dysmorphic features.


American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162938

American Academy of Pediatrics. Choosing a Child Care Center. play/Pages/Choosing-a-Childcare-Center.aspx. Accessed January 6, 2020.

Bickley LS, Hoekelman RA. Bates’ Guide to Physical Examination and History Taking. 7th ed., Philadelphia: Lippincott; 1999.

Bickley LS, Hoekelman RA. Bates’ Guide to Physical Examination and History Taking. 7th ed., Philadelphia: Lippincott; 1999:687-688.

Bickley LS, Hoekelman RA. Bates’ Guide to Physical Examination and History Taking. 7th edition, Philadelphia: Lippincott; 1999.

Breastfeeding and the Use of Human Milk. American Academy of Pediatrics. Accessed August 16, 2021.

Bright Futures Guidelines and Pocket Guide. Bright Futures. Accessed October 22, 2020.

Bright Futures Guidelines and Pocket Guide. Bright Futures. Accessed October 23, 2020.

CDC Vaccine Schedules App for Health Care Providers. Center for Disease Control and Prevention. Accessed January 6, 2020

Childproofing your home. American Academy of Pediatrics. home/Pages/Childproofing-Your-Home.aspx. Accessed October 22, 2020.

Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening [published correction appears in Pediatrics. 2006 Oct;118(4):1808-9]. Pediatrics. 2006;118(1):405-420. doi:10.1542/peds.2006-1231

Earls MF; Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126(5):1032-1039. doi:10.1542/peds.2010-2348

FDA proposes limit for inorganic arsenic in infant rice cereal. USFDA. proposes-limit-inorganic-arsenic-infant-rice-cereal. Accessed January 6, 2020

Fox D, Brittan M, Stille C. The Pediatric Inpatient Family Care Conference: a proposed structure toward shared decision-making. Hosp Pediatr. 2014;4(5):305-310. doi:10.1542/hpeds.2014-0017 Accessed September 29, 2020

Glascoe FP, Roberstshaw NS, Ellsworth & Vandermeer Press, LLC, 1013 Austin Court, Nolensville, TN 37135. Accessed February 11, 2019.

Immunization Schedules. Centers for Disease Control and Prevention. Accessed January 6, 2020

Immunizations schedules. Centers for Disease Control and Prevention. Accessed January 6, 2020

Lipkin PH, Macias MM; COUNCIL ON CHILDREN WITH DISABILITIES, SECTION ON DEVELOPMENTAL AND BEHAVIORAL PEDIATRICS. Promoting Optimal Development: Identifying Infants and Young Children With Developmental Disorders Through Developmental Surveillance and Screening. Pediatrics. 2020;145(1):e20193449. doi:10.1542/peds.2019-3449

Neuroblastoma-Childhood Guide, American Society of Clinical Oncology Cancer.Net types/neuroblastoma-childhood/introduction Accessed September 29, 2020

Nutrition and Supplement Use. AAP. Use.aspx. Accessed January 6, 2020

Reach Out & Read. Accessed October 22, 2020.

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Responding to Parents. Immunization Action Coalition. Accessed January 6, 2020

SIDS and Other Sleep-Related Infant Deaths: Updated 2016 Recommendations for a Safe Infant Sleeping Environment. AAP Updated 2016 Recommendations for a Safe Infant Sleeping Environment. Accessed January 6, 2020.

Sample Menu for an 8 to 12 Month Old. AAP. nutrition/Pages/Sample-One-Day-Menu-for-an-8-to-12-Month-Old.aspx. Accessed January 6., 2020

Shelov S, ed. Caring for Your Baby and Young Child: Birth to Age 5. American Academy of Pediatrics. New York: Bantam; 1998.

Shojaei-Brosseau T, Chompret A, Abel A, et al. Genetic epidemiology of neuroblastoma: a study of 426 cases at the Institut Gustave- Roussy in France. Pediatr Blood Cancer. 2004;42(1):99-105. doi:10.1002/pbc.10381 Accessed September 29, 2020

Starting solid foods. AAP. Accessed January 6, 2020

Tips to reduce arsenic in your baby’s diet. AAP. nutrition/Pages/reduce-arsenic.aspx. Accessed January 6, 2020

Vaccine Adverse Event Reporting System (VAERS). Centers for Disease Control and Prevention. Accessed January 6, 2020

WHO Growth Standards Are Recommended for Use in the U.S. for Infants and Children 0 to 2 Years of Age. Centers for Disease Control and Prevention. Accessed January 6, 2020

Wagner, CL, Greer, FR, and the section on Breastfeeding and Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents: American Academy of Pediatrics Clinical Report. Pediatrics 2008;122(5); 1142-1152. Accessed January 6, 2020.

Why Formula Instead of Cow’s Milk? American Academy of Pediatrics. stages/baby/feeding-nutrition/Pages/Why-Formula-Instead-of-Cows-Milk.aspx. Accessed February 2, 2020.

Zitelli BJ, Davis HW. Atlas of Pediatric Physical Diagnosis. 4th ed., St. Louis, MO: C.V. Mosby; 2002:58.

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  • Pediatrics 02: Infant female well-child visits (2, 6, and 9 months)
    • Learning Objectives
    • Knowledge
      • Components of a Well-Child Visit
      • Nutrition Guidance
      • Early Growth
      • Caloric Requirements of 1- to 2-Month-Olds
      • The Red Reflex
      • Moro Reflex
      • Infant Rashes
      • Developmental Surveillance and Screening
      • Anticipatory Guidance at the 2-month Visit
      • Car Seat Safety
      • Immunizations in Childhood
      • Typical Early Childhood Growth Patterns
      • 6-Month Developmental Milestones
      • Child-Proofing the Home
      • Anticipatory Guidance at the 6-month Visit
      • Annual Review of the Immunization Schedule
      • Acetaminophen and Vaccines
      • 12 Month Developmental Milestones
      • Prognosis of Stage 4S Neuroblastoma
      • Genetics of Neuroblastoma
    • Clinical Skills
      • Growth Parameters
      • Introducing Difficult News
    • Studies
      • Initial Testing
    • Clinical Reasoning
      • Differential Diagnosis for RUQ Mass and Pallor in a 9-Month-Old Infant
    • References