4: 8-year-old male well-child check

Question 1

BMI

Answer 1

weight (in kg) divided by height (in meters) squared.

Question 2

Weight/Height age

Answer 2

Age at which the patient’s weight/height would plot at the 50th percentile.

Question 3

core symptoms of ADHD are:

Answer 3

-Inattention -Hyperactivity -Impulsivity

Question 4

Prevalence of ADHD

Answer 4

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.

Question 5

ADHD Diagnosis

Answer 5

based on a set of characteristic clinical findings.

Question 6

Important Causes of School Failure: Sensory impairment

Answer 6

-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.

Question 7

Important Causes of School Failure: sleep disorder

Answer 7

-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.

Question 8

Important Causes of School Failure: Mood Disorder

Answer 8

-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.

Question 9

Important Causes of School Failure: Learning disability

Answer 9

-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.

Question 10

Important Causes of School Failure: Conduct

Answer 10

-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.

Question 11

“Red Flags” for Risk of Learning Disability

Answer 11

–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

Question 12

Response to ADHD Medication

Answer 12

Eighty percent of children with ADHD respond to stimulant medications such as sustained-release methylphenidate.

Question 13

Adverse Effects of ADHD Medications

Answer 13

1. appetite suppression2. insomnia3. decrease in growth velocity

Question 14

Epidemiology of Obesity

Answer 14

-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.

Question 15

Prenatal/neonatal risk factors for obesity include

Answer 15

high birth weight and maternal diabetes.

Question 16

Having an obese parent increases a child’s risk for adult obesity, and the risk increases significantly if bothparents are obese

Answer 16

-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.

Question 17

Complications of Obesity

Answer 17

-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.

Question 18

American Diabetes Association (ADA) Diagnostic Criteria

Answer 18

-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

Question 19

Guidelines for Screening for Diabetes Mellitus in Children: Risk Criteria

Answer 19

-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

Question 20

Age of initiation of screening for Diabetes Mellitus in Children

Answer 20

-10 years of age or at onset of puberty, whichever is earlier-every 3 yrs

Question 21

Classification of Hypertension in Children

Answer 21

<90 nml90-95 pre HTN95-99 plus 5mm Hg: stage 1>99 plus 5mm Hg: stage 2

Question 22

Weight Gain vs. Underlying Endocrinological Disorder

Answer 22

-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.

Question 23

Causes of Elevated BP Measurements

Answer 23

-white coat HTN-positioning-painful stimuli-cuff size

Question 24

Screening for Secondary Hypertension in Children

Answer 24

-umbilical arterial or venous access-UTI-Catecholamine excess-Fhx or renal dz-coarctation of the aorta

Question 25

Management of PRE-Hypertension in Children

Answer 25

-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.

Question 26

Management of Primary Hypertension in Children

Answer 26

-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

Question 27

Developing a Weight Management Plan With the Family

Answer 27

-diet-screen time-physical activity

Question 28

Initial Treatment of ADHD

Answer 28

-starting a med-monitoring for efficacy-additional consults

Question 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?

Answer 29

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.

Question 30

Tanner 1

Answer 30

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.

Question 31

Tanner 2

Answer 31

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.

Question 32

Tanner 3

Answer 32

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.

Question 33

Tanner 4

Answer 33

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.

Question 34

Tanner 5

Answer 34

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.

Question 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?

Answer 35

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

Question 36

Boys progression of puberty

Answer 36

-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