4 Flashcards
PCOM mnemonic for ear check
Position- retracted vs bulging
Color - pearly gray, red, amber/yellow
Opacity - translucent, opaque
Mobility - normal vs decreased
BMI
BMI 85-95th percentile is overweight. A BMI greater than the 95th percentile for age is considered obese.
Can take the BMI of anyone 2 and older
Growth curve terms
Weight age = Age at which the patient’s weight would plot at the 50th percentile.
Height age = Age at which the patient’s height would plot at the 50th percentile.
Helps reference how big or small the child is
Attention deficit hyperactivity disorder (ADHD)
Symptoms
Prevalence
Dx
Comorbidities - 3
Symptoms
The core symptoms of ADHD are:
Inattention
Hyperactivity
Impulsivity - trouble taking turns, interrupts others during play or conversation
Other conditions that must be met:
Several inattentive or hyperactive-impulsive (6 of the symptoms) symptoms were present for at least 6 months and are inappropriate for the person’s developmental age
Several symptoms must be present before age 12 years
Symptoms are evident in two or more settings, (e.g., at home, school or work; with friends or relatives; in other activities).
Symptoms interfere with the individual’s functioning socially or at school or work
Symptoms are not attributable to another mental disorder
Prevalence
The estimated prevalence in the U.S. is about 8-10%, making ADHD the most common neurobehavioral disorder of childhood and among the most common chronic health conditions in school-aged children.
Diagnosis
There is no laboratory test for the diagnosis of ADHD. Rather, the diagnosis is based on a set of characteristic clinical findings.
Oppositional defiant disorder and conduct disorder has highest comorbidity, learning disability is a common comorbidity, mood disorder may accompany or mimic ADHD
Important causes of school failure
Sensory impairment Hearing and vision impairment in particular, may mimic inattention.
Newborns are universally screened for hearing in maternity hospitals as part of their newborn care.
Vision and hearing should be screened subjectively (i.e., by history) in infants and toddlers.
Objective vision screening should be part of health maintenance visits beginning at 3 years old.
Objective hearing screening should be performed on all newborns and should be resumed at the 4-year-old health maintenance visit.
View the AAP Recommendations for Preventive Pediatric Health Care
Sleep disorder
Inadequate sleep may adversely affect school performance.
This may be due to a formal sleep disorde r (e.g., obstructive sleep apnea, narcolepsy) or simply poor bedtime routines in the home (poor “sleep hygiene”).
Patients with ADHD often have poor sleep hygiene, but typically do not seem overtired.
Mood disorder
Prevalence of mood disorders increases with age.
Depression affects an estimated 1-2% of elementary school age children and 5% of adolescents.
Childhood depression is marked by a high rate of conversion to bipolar disorders.
Children with ADHD also have a higher rate of mood disorders than control populations.
Mood disorders may mimic OR accompany ADHD.
Learning disability
A learning disability (LD) is a disorder of cognition which manifests itself as a problem involving academic skills.
Most states require documentation of a discrepancy between IQ (in the normal range) and academic achievement for the diagnosis of a learning disability.
Learning disabilities clearly impair academic performance, but may also lead to behavioral and attention problems, particularly at school.
Comorbidity between LD and ADHD is common; many experts feel that one diagnosis should not be made without evaluating for the other.
Conduct disorder
Oppositional defiant disorder (ODD) is characterized by a pattern of negativistic, hostile and defiant behavior.
Conduct disorder (CD) is a more severe disorder of habitual rule-breaking, characterized by a pattern of aggression, destruction, lying, stealing and/or truancy.
ODD/CD is the psychiatric condition with the highest comorbidity rates with ADHD.
Red flags for learning disability
History of maternal illness or substance abuse during pregnancy
Complications at the time of delivery
History of meningitis or other serious illness
History of serious head trauma
Parental history of learning disabilities or difficulty at school
Adverse effects of ADHD meds - 4
Appetite suppression
The most common adverse effect associated with stimulant use.
Weight loss, if any, is typically minor.
Tic disorders
Does not cause tic disorder, but can unmask them or make them more prominent
Insomnia
A common, dose-related side effect.
Typically worse on the first days of medication.
Decrease in growth velocity
Studies have shown a slight decrease in growth velocity in children on stimulant medications for ADHD in the range of 1 to 2 cm, particularly when children were on higher and more consistently administered doses.
The effects diminished by the third year of treatment but no compensatory rebound effects were found.
Growth should be closely monitored for children on these medications.
Rf for obesity 4
Prenatal/neonatal risk factors for obesity include high birth weight and maternal diabetes.
Having an obese parent increases a child’s risk for adult obesity, and the risk increases significantly if both parents are obese:
Odds ratio for one parent is 3
Odds ratio for both parents is more than 10
Before age 3 years, parental obesity is a stronger predictor of obesity in adulthood than child’s weight status.
Children from families of lower socioeconomic status have higher rates of obesity. This is likely due to multiple factors, including lack of safe places for physical activity and less access to nutrient rich, healthy foods and beverages.
Certain genetic syndromes (such as Prader-Willi, Bardet-Biedl, and Cohen syndromes) are known to be associated with obesity.
Complications of obesity 6
Sleep apnea is cessation of breathing lasting at least 15 seconds while sleeping. It is obstructive, rather than central, apnea and is characterized by loud snoring and labored breathing. It is estimated to occur in approximately 7% of overweight children.
Dyslipidemia Hypertriglyceridemia and low HDL cholesterol is strongly correlated with metabolic syndrome, which occurs almost exclusively as a consequence of obesity. Several studies have shown that dyslipidemia may improve with weight reduction.
Hypertension Hypertension has been found to occur up to nine times more frequently in overweight children, and approximately 1/3 of children with a BMI greater than the 95th percentile are hypertensive.
Slipped capital femoral epiphysis (SCFE)
SCFE involves the displacement of the femoral head from the femoral neck through the physeal plate.
Most commonly, it occurs at the onset of puberty in obese patients with delayed sexual maturation.
Typical symptoms include an antalgic gait due to pain referred to the hip, thigh and/or knee, with limited range of motion (especially internal rotation) on examination of the hip.
SCFE can be diagnosed on plain x-rays of the pelvis, which shows widening of the physis.
See a radiological case on SCFE.
Type 2 diabetes mellitus Obesity is the most prominent risk factor for the development of Type 2 DM in children. The average BMI for pediatric patients with Type 2 DM ranges from 35-39 kg/m2 vs. the normal pediatric range (5th-95th percentile) of about 15-27 kg/m2. There is no increased risk of Type 1 DM.
Steatohepatitis
Nonalcoholic fatty liver disease, steatohepatitis, has been associated with obese adolescents and is typically characterized by a mild increase in liver transaminases, a hyperechoic liver on ultrasound, and evidence of fatty infiltration and fibrosis on biopsy.
Diabetes mellitus
Dx and presentation
Screening
Classification
Diabetes mellitus (DM) has previously been classified by age of onset (i.e., juvenile vs. adult-onset) or by type of therapy (insulin-dependent vs. non-insulin dependent). Classification by etiology is now preferred:
Type 1 DM is characterized by insulin deficiency, typically due to autoimmune destruction of pancreatic beta cells.
Type 2 DM is more heterogeneous, but typically involves insulin resistance.
Type 2 DM has been recognized in children only recently. Although the data regarding incidence is inexact, the trend for Type 2 DM, like that of childhood obesity, is clearly rising.
American Diabetes Association (ADA) Diagnostic Criteria
HbA1c ≥ 6.5% (48 mmol/mol) (test performed in an appropriately certified laboratory) or
Fasting (defined as no caloric intake for at least 8 hours) plasma glucose ≥ 126mg/dL (7.0 mmol/L) or
2-hour plasma glucose ≥ 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test following a glucose load of 75 g glucose or
In a patient with symptoms of hyperglycemia, a random plasma glucose ≥ 200mg/dL
Presentation
Patients with Type 2 DM typically have a more indolent presentation than patients with Type 1 DM.
Weight loss is less common, and DKA is rare, although 25% of patients with Type 2 DM will have ketonuria at diagnosis.
“Accidental” diagnosis by routine laboratory screening, especially urinalysis, occurs in up to one third of patients with Type 2 DM; this is rare in Type 1 DM.
Type I DM is more likely to present in early childhood; age is not generally helpful in differentiating between Type 1 and Type 2 DM in adolescence.
Age of initiation of screening
10 years of age or at onset of puberty, whichever is earlier
Recommended screening frequency
Every 3 years
How a bp cuff should fit
A BP cuff should cover 2/3 of the upper arm.
The internal bladder should encircle 80-100% of the arm circumference.
Htn in children
BP percentile Classification
< 90th Normal
90th-95th Prehypertension
95th-99th plus 5 mm Hg Stage 1 hypertension
> 99th plus 5 mm Hg Stage 2 hypertension
As with adults, adolescents with BP levels > 120/80 mm Hg, but < 95th percentile should be considered prehypertensive.
Screening for secondary htn in children - 5 things to ask about
Umbilical Arterial or Venous Access
Placement of an umbilical arterial or venous line during the perinatal period may predispose to renal vascular disease.
Urinary Tract Infection
Although less common in boys, UTIs in childhood are one of the leading causes of hypertension and renal insufficiency later in life. This is due to renal scarring following the infection.
Catecholamine Excess
Although some children with catecholamine excess, e.g., pheochromocytoma or neuroblastoma, may not have symptoms such as flushing or sweating or palpitations, a positive response to a screening question in a hypertensive child would merit urine catecholamine testing.
Family History of Renal Disease
Ask about family history for hypertension and kidney disease. Inquiring whether a family member has needed dialysis is a good screening question for severe kidney disease.
Coarctation of the Aorta
Some children with coarctation of the aorta may go undetected until presenting with hypertension at a school-age visit. On exam, pay special attention to the femoral pulses and consider documenting BP measurement in a lower extremity.
Acanthosis nigricans
Acanthosis Nigricans
Acanthosis nigricans is associated most commonly with obesity and may be a marker for insulin resistance (with or without polycystic ovary syndrome). Lesions often improve with weight loss. It is characterized by hyperpigmentation and hyperkeratosis: Lesions are dark, “velvety,” “dirty-looking” areas of thickened skin.
Most commonly involved sites include:
Posterior neck
Axillae
Intertriginous areas (areas where opposing skin surfaces touch and may rub–e.g., skin folds of the groin, axillae, and breasts)
Over bony prominences.
Prochaska model for stages of change 6
Pre-contemplation: Patient: “Problem? What problem?”
The physician’s role is to provide advice and information to help the patient develop an awareness of the need for change.
C ontemplation: Patient is ambivalent; sees the need for change, but rationalizes why change is either not possible or desirable.
Physician’s role is to recognize the ambivalence, to support motivating factors and help alleviate barriers to change. (Mrs. Thompson was at this stage at the first visit regarding Jimmy’s methylphenidate. She was not ready to move on to action until her concerns about the medication were addressed.)
Determination: Patient: “I must change; I can do it.” At this stage, the patient is “talking the talk.”
Physician helps to design a plan and problem-solve.
Action: Patient: “What can I do? Who can help?” Here, patient is “walking the walk.”
Physician reinforces action, helps to anticipate and deal with withdrawal.
Maintenance: Patient feels satisfaction; patient may reinforce this stage by being a role model for others.
Relapse: Patient feels loss of control, demoralization.
Physician needs to be available for support, identify antecedents of relapse, help patient re-enter pathway for change above.
