PRIMITIVE REFLEXES
Moro (startle)
normal until 4–6 months. Persistence after 6 months = neurological concern.
VSD (Ventricular Septal Defect)
Most common CHD — hole between lower chambers. Small ones may close on their own. Large ones cause heart failure: poor feeding, sweating with feeds, rapid breathing.
Ages 1–3 years
Gains ~4–5 lbs and 3 inches/year. Physiological anorexia (decreased appetite) is NORMAL — do not force feed.
Drowning
leading cause of accidental death ages 1–4. Can drown silently in 2 inches of water. Never leave
near any water source alone.
Pyloric Stenosis
Pyloric muscle thickens, blocking food passage. Ages 2–8 weeks, more common in firstborn males. Projectile vomiting immediately after every feeding — baby still hungry after. Olive-shaped mass in RUQ. Metabolic alkalosis from vomiting. Treatment: pyloromyotomy (surgery).
Babinski (toes fan when sole stroked)
normal until 12–18 months.
PDA (Patent Ductus Arteriosus)
Fetal vessel between aorta and pulmonary artery stays open. Common in
premature infants. 'Machine-like' continuous murmur. Treatment: indomethacin or surgery.
Erikson: Autonomy vs Shame and Doubt
toddlers need to do things independently. Saying 'no' is healthy.
Offer safe choices: 'red cup or blue cup?'
Choking hazards
hot dogs, grapes, nuts, popcorn, hard candies, coins. Cut food into small pieces.
Intussusception
Bowel telescopes into itself, cutting off blood supply. Ages 3 months–3 years. Sudden severe
colicky pain (knees to chest, then fine between spasms), vomiting, then currant jelly stools (blood + mucus).
Emergency — air enema or surgery.
Rooting/sucking
3–4 months. Palmar grasp: disappears ~3–4 months.
Tetralogy of Fallot (4 defects)
VSD + overriding aorta + pulmonary stenosis + right ventricular hypertrophy.
Cyanotic. Boot-shaped heart on X-ray. 'Tet spells' with crying or exertion.
Piaget: Early preoperational stage.
Symbolic thinking begins around 18 months — pretend play starts.
Poisoning
lock all medications, cleaning products. Poison Control: 1-800-222-1222.
Hirschsprung Disease
Absent ganglion cells in colon — no peristalsis in that section. Newborn fails to pass
meconium within 48 hours. Chronic constipation, abdominal distension, ribbon-like stools. Diagnosis: rectal
biopsy. Treatment: surgery.
TET SPELL MANAGEMENT
IMMEDIATELY place in knee-chest position — increases systemic resistance, forces more blood through lungs.
Give O2, call provider. Do NOT lay child flat.
Parallel play
toddlers play NEXT TO peers, not WITH them — watching and imitating. This is completely normal.
TOILET TRAINING READINESS
Stays dry 2+ hours · Can pull pants up/down · Shows interest and awareness · Follows simple instructions.
Average age 2–3 years. Never force — it backfires.
Appendicitis
RLQ pain, low-grade fever, nausea/vomiting, rebound tenderness, McBurney's point. Position of
comfort: right side with knees flexed.
NEVER apply heat to the abdomen — increases blood flow and can cause rupture. Never give enemas or
laxatives. Keep NPO and call surgeon.
KAWASAKI DISEASE
Inflammatory disease of blood vessels. Most dangerous complication: coronary artery aneurysms (can cause heart attack in toddlers).
Conjunctivitis (red eyes, no discharge) · Rash (polymorphic) · Adenopathy (cervical nodes) · Strawberry tongue ·
Heat (fever 5+ days >38.5C). Treatment: high-dose aspirin + IVIG.
Temper tantrums
peak at 2–3 years. Cause: frustration with communication and limits. Strategy: stay calm,
don't give in, keep child safe, offer choices after tantrum.
DEHYDRATION Signs
dry mucous membranes, no tears, sunken eyes and fontanel, decreased urine output (dark urine), poor
skin turgor (tents when pinched), lethargy.
Celiac disease
Autoimmune reaction to gluten destroys intestinal villi. Signs: chronic diarrhea, steatorrhea,
weight loss, abdominal bloating, failure to thrive. Treatment: strict lifelong gluten-free diet — even
cross-contamination (shared toaster) causes damage.