4: 8-year-old male well-child check Flashcards
1
Q
BMI
A
weight (in kg) divided by height (in meters) squared.
2
Q
Weight/Height age
A
Age at which the patient’s weight/height would plot at the 50th percentile.
3
Q
core symptoms of ADHD are:
A
- Inattention
- Hyperactivity
- Impulsivity
4
Q
Prevalence of ADHD
A
U.S.: 8-10%, making ADHD the most common neurobehavioral disorder of childhood and among the most common chronic health conditions in school-aged children.
5
Q
ADHD Diagnosis
A
based on a set of characteristic clinical findings.
6
Q
Important Causes of School Failure: Sensory impairment
A
- 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.
7
Q
Important Causes of School Failure: sleep disorder
A
- 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.
8
Q
Important Causes of School Failure: Mood Disorder
A
- 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.
9
Q
Important Causes of School Failure: Learning disability
A
- 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.
10
Q
Important Causes of School Failure: Conduct
A
- 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.
11
Q
“Red Flags” for Risk of Learning Disability
A
- -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 h/o learning disabilities or difficulty at school
12
Q
Response to ADHD Medication
A
Eighty percent of children with ADHD respond to stimulant medications such as sustained-release methylphenidate.
13
Q
Adverse Effects of ADHD Medications
A
- appetite suppression
- insomnia
- decrease in growth velocity
14
Q
Epidemiology of Obesity
A
- The prevalence of childhood obesity has doubled in the past 20 years in the U.S.
- Currently, approximately 15% of 6- to 19-year-olds are at or above the 95th percentile for BMI on standard growth charts, with even higher rates among certain minority populations.
- The probability of childhood obesity persisting into adulthood increases from 20% at age four to 80% by adolescence.
- Multiple factors besides diet and activity level can contribute to obesity, including genetic and environmental RF.
15
Q
Prenatal/neonatal risk factors for obesity include
A
high birth weight and maternal diabetes.
16
Q
Having an obese parent increases a child’s risk for adult obesity, and the risk increases significantly if both
parents are obese
A
- 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.
17
Q
Complications of Obesity
A
- sleep apnea
- dyslipidemia
- HTN
- slipped capital femoral epiphysis (SCFE)
- –Most commonly, it occurs at the onset of puberty in obese patients with delayed sexual maturation
- T2DM
- Steatohepatitis (Nonalcoholic fatty liver disease)
- –characterized by a mild increase in liver transaminases, a hyperechoic liver on ultrasound, and evidence of fatty infiltration and fibrosis on biopsy.
18
Q
American Diabetes Association (ADA) Diagnostic Criteria
A
- HbA1c ≥ 6.5% (48 mmol/mol) (Test performed in an appropriately certified laboratory.), or
- Fasting plasma glucose ≥ 126mg/dL (7.0 mmol/L) (Fasting is defined as no caloric intake for at least 8 hours), or
- Two-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
19
Q
Guidelines for Screening for Diabetes Mellitus in Children: Risk Criteria
A
- Overweight (i.e., BMI > 85th percentile; weight:height > 85th percentile; or weight > 120% ideal for height) plus any two of the following risk factors:
- FHx of Type 2 DM in first- or second-degree relative
- Race/ethnicity (NA, AA, HA, Asian/South Pacific Islander)
- Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, polycystic ovary syndrome, hypertension, dyslipidemia)
- Maternal h/o diabetes or gestational diabetes during the child’s gestation
20
Q
Age of initiation of screening for Diabetes Mellitus in Children
A
- 10 years of age or at onset of puberty, whichever is earlier
- every 3 yrs
21
Q
Classification of Hypertension in Children
A
<90 nml
90-95 pre HTN
95-99 plus 5mm Hg: stage 1
>99 plus 5mm Hg: stage 2
22
Q
Weight Gain vs. Underlying Endocrinological Disorder
A
- Endocrine diseases that cause weight gain usually limit growth and lead to short stature.
- In most cases, obesity stimulates statural growth and leads to tall stature for age. It also typically advances bone age and leads to early puberty.
23
Q
Causes of Elevated BP Measurements
A
- white coat HTN
- positioning
- painful stimuli
- cuff size
24
Q

Screening for Secondary Hypertension in Children
A
- umbilical arterial or venous access
- UTI
- Catecholamine excess
- Fhx or renal dz
- coarctation of the aorta
25
Management of PRE-Hypertension in Children
- Therapeutic lifestyle changes should be implemented
- BP should be followed up in 6mo
- Guidelines do not recommend a diagnostic workup for a secondary cause of HTN for children with bp in the preHTN range unless there is a concern for a possible underlying cause in the patient's medical hx, exam, or FHx.
26
Management of Primary Hypertension in Children
- Medications (typically reserved for children with Stage 2 HTN, children with secondary hypertension, and children with evidence of target-organ effects)
- Dietary changes
- Weight loss (if overweight)
- Physical activity
27
Developing a Weight Management Plan With the Family
- diet
- screen time
- physical activity
28
Initial Treatment of ADHD
- starting a med
- monitoring for efficacy
- additional consults
29
Billy, a 7-year-old boy, presents to the clinic with complaints of headaches and episodes of feeling sweaty and flushed. He also reports that at times he feels as if his heart is racing. Billy was full term, had an uncomplicated birth, and has been otherwise healthy until now. On exam his BP is 120/80 mmHg and is the same in his upper and lower extremities. His weight and height are in the 50th percentile for his age. What is a likely cause of Billy's hypertension?
Catecholamine excess (pheochromocytoma or neuroblastoma) should be suspected in a child who is hypertensive and has episodes of sudden sweating, flushing, or feels that his heart is racing. Billy is exhibiting these signs and a urine catecholamine testing would be appropriate in this case.
30
Tanner 1
breast development consists of no glandular tissue and is prepubertal. Tanner Stage I consists of no pubic hair at all. This is usually around age 10 or younger.
31
Tanner 2
breast development occurs when breast buds form and the areola begins to widen. A small amount of long, downy hair with slight pigmentation appears on the labia majora. This patient's elevated breast buds and pubic hair distribution puts her beyond Tanner Stage II.
32
Tanner 3
Her breast buds are elevated but do not have the secondary mound characteristic of Tanner Stage IV. Her pubic hair distribution extends more laterally than Stage II but is not adult-like in hair quality and does not extend onto the mons pubis.
33
Tanner 4
breasts are increased in size and elevation and the areola and papilla form a secondary mound that projects from the contour of the rest of the breast, and the pubic hair extends across the mons pubis and spares the medial thighs.
34
Tanner 5
breasts reach their adult size and the areola returns to the contour of the surrounding breast while the central papilla remains projecting and the pubic hair extends to the medial surface of the thighs.
35
A 10-year-old female comes to the clinic for a well child exam. Her mom asks about puberty and wants to know in what order she should expect to see normal developmental changes in her daughter. Which of the following sequences is correct?
breast buds are the first sign (10-11 years),
followed by pubic hair (10-11 years),
then a growth spurt (12 years),
and then menarche (12-13 years).
Most girls reach adult height by approximately 15 years
36
Boys progression of puberty
- The first sign of puberty in a boy is testicular enlargement. The onset of puberty is quite variable, but usually occurs between 10 and 15 years for boys. It is rare for boys not to have begun puberty by the age of 16.
- Pubic hair appearance occurs around 12 years of age, and is usually the second sign of puberty following testicular enlargement
- Growth of the penis occurs with growth of the scrotum, and usually occurs around 13-14 years of age.
- First ejaculations usually occur around 13-14 years of age.
- A growth spurt is usually not appreciated until at least 14 years of age for most boys
