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Pediatrics > Case 4: 8yo WCC > Flashcards

Case 4: 8yo WCC Flashcards

1
Q

discuss the factors that contribute to childhood obesity

A
  • food as reward
  • poor food choices / options at home and school
  • sweetened drinks
  • poor exercise
  • increased screen time (TV, video games) > 1h/d
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2
Q

health implications of childhood obesity

A
  • OSA
  • SCFE
  • LE joint pain
  • high cholesterol
  • diabetes (T2DM) in a child (+/- acanthosis nigricans)n
  • HTN
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3
Q

typical presentation of ADHD in children

A
  • “he never listens at home or at school”
  • he’s always on the, he’s very loud and on full speed. he never sits still for long
  • disruptive at school; loses interest quickly even in sports
  • teachers comment that he doesn’t focus
  • he does his work halfway / rushes through it so quickly that he makes careless mistakes
  • otherwise seems like he’s on his own planet
  • doesn’t sleep much at home; doesn’t feel sleepy (poor sleep hygiene, but does not seem overly tired)
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4
Q

diffdx for school failure

- when to screen

A
  • hearing problems –> universal screening as newborn & 4yo
  • vision problems –> screen @ 3yo
  • hx of maternal illness / substance abuse during pregnancy
  • hx of meningitis or other serious illness
  • hx of serious head trauma
  • familial problems with academic difficulty
  • learning disability - poor academic performance, behavioral & attention problems at school
  • poor sleep = OSA, narcolepsy, poor sleep hygiene
  • mood d/o - depression (high rate of conversion to bipolar d/o)
  • conduct d/o = habitual rule-breaking, aggression, destruction, lying, stealing, and truancy
    v. oppositional defiant d/o (LESS SEVERE - negativistic, hostile, defiant behavior)
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5
Q

criteria for ADHD

A

inattention
impulsivity
hyperactivity

–> leading to problems in 2 environments (home, school)

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6
Q

what is the starting dose for ADHD meds in an child <10yo

A

Methylphenidate 18mg PO daily

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7
Q

8yo boy who is in the 90th percentile for weight comes in with a BP of 120/80. what are your concerns?

A

Underlying concerns for obesity and thus HTN, normal for 6-12yo SBP is 80-120

  • Could be high
  • could be errors in measurement (most elevated BP in children are errors) –> CONFIRM
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8
Q

8yo boy who is in the 90th percentile for weight comes in with a BP of 120/80. what are your concerns?

A

Underlying concerns for obesity and thus HTN, normal for 6-12yo SBP is 80-120

  • Could be high
  • could be errors in measurement (most elevated BP in children are errors) –> CONFIRM
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9
Q

what recommendations can you give for a child who is overweight

A
  • low-calorie snacks (fruits, veggies, water, sugar-free drinks). Friday = “cheat day”
  • decrease screen time to <2h/d; remove TV from bedroom
  • increase daily activity to 60min of activity/day.
  • parents to change foods in the house

Labs
- fasting glucose, lipids, AST, ALT

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10
Q

what recommendations can you give for a child who is hypertensive

A
  • qweekly BP check

- no-added salt diet

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11
Q

BMI calculation

and what is it good for?

A

kg/m2

(weight in kg) / (height in m)^2

==>reflects amount of body fat (v. weight-for-height measurements)

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12
Q

what percentile of BMI for age would be considered obese for a child? how would you calculate it?

A

> 95th percentile = OBESE
85-95%ile = OVERWEIGHT

BMI plotted on the chart, related to age (weight for age curves)

Reported in terms of: he “weighs/height as much as the average X-year old”

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13
Q

Is there evidence that shows that sugar causes overactivity or distractibility.

A

No evidence shown

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14
Q

symptoms of inattention

A
  • does not pay attention to detail or makes careless mistakes in school / work
  • trouble holding attention
  • trouble listening when spoken to directly
  • loses focus, easily distracted
  • difficulty with organization of tasks
  • reluctant to do tasks requiring sustained mental effort
  • often loses things
  • often forgetful in daily activities
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15
Q

symptoms of inattention

A
  • does not pay attention to detail or makes careless mistakes in school / work
  • trouble holding attention
  • trouble listening when spoken to directly
  • loses focus, easily distracted
  • difficulty with organization of tasks
  • reluctant to do tasks requiring sustained mental effort
  • often loses things
  • often forgetful in daily activities
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16
Q

sxs of hyperactivity and impulsivity

A
  • fidgety, sqiurms in seat
  • difficulty remaining seated when expected
  • runs / climbs in inappropriate places
  • difficulty playing quietly
  • always “on the go”
  • talks too much
  • blurts out an answer too soon/trouble taking turns
  • interrupts others who are playing / speaking
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17
Q

in addition to sxs of inattention, hyperactivity, and impulsivity, what other conditions must be med for a diagnosis of ADHD

A
  • present for >/= 6mo; inappropriate for developmental age
  • present < 12y
  • evident in 2+ settings
  • interfere w/ individual’s functioning socially or at school/work
  • not attributable to another mental disorder
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18
Q

Negative associations with TV viewing

A
  • increased violent / aggressive behavior
  • poor body image
  • substance use
  • early sexual activity
  • obesity
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19
Q

how does increased TV time worsen obesity?

A
  • lack of more active pursuits
  • unhealthy diet
  • negative sleep habits
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20
Q

AAP recommendations for children’s TV time

A
  • limit to 1-2h/d of quality TV

- remove TV from bedroom

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21
Q

define: acanthosis nigricans

diffdx

A

==> dark, “velvety” “dirty-looking” areas of thickened skin (hyperpigmentation, hyperkeratoss)
locations = posterior neck; axillae; intertriginous areas; over bony prominences

insulin resistance

  • obesity
  • T2DM
  • PCO2

improve with weight loss

22
Q

prochaska’s model for stages of behavioral change

  • what is the pt thinking?
  • what should the Dr. do?
A

1) pre-contemplation - pt doesn’t see the problem ==> Dr. to provide advice, info to help awareness
2) Contemplation - pt sees need for change, but can’t find the motivation ==> Dr. encourage, alleviate barriers & concerns
3) Determination - pt wants to change and asking for help ==> Dr. develop plan, problem-solve
4) Action Action - pt taking charge and taking steps to start to change ==> Dr. reinforce action, anticipate roadblocks, help withdrawal
5) Maintenance - pt satisfied, role model for others
6) Relapse - pt losing control, hard to maintain, demoralized ==> Dr. support, anticipate relapse, help fine same / new avenues.

23
Q

define: weight age

A

age at which the pt’s weight would plot at the 50th percentile

24
Q

define: height age

A

age at which the pt’s height would plot at the 50th percentile

25
Q

overlap between school failure and ADHD

A

ADHD

  • poor sleep hygiene
  • more mood d/o
  • learning disability
  • oppositional defiant d/o / conduct d/o
26
Q

overlap between mood d/o and ADHD

A

Mood d/o can mimic or accompany ADHD

27
Q

difference between oppositional defiant d/o and conduct d/o

A
  • conduct d/o = habitual rule-breaking, aggression, destruction, lying, stealing, and truancy
    v. oppositional defiant d/o (LESS SEVERE - negativistic, hostile, defiant behavior)
28
Q

red flags for risk of learning disability

A
  • hx maternal illness / substance abuse during pregnancy
  • complications at delivery
  • hx meningitis or other serious illness
  • hx serious head trauma
  • parental hx of learning disbilities
29
Q

adverse effects of ADHD meds

A
  • appetite suppression (+/- minor weight loss)
  • insomnia (esp. at beginning)
  • slight decrease in growth velocity of 1-2cm (effects diminished by 3rd year of treatment)

RARER SIDE EFFECTS

  • addiction (iif abused)
  • personality changes = dull, restricted, over-focused (wrong med / dose)
  • CV risk for children with heart disease, adults
  • unmasking of tic disorders

NO EVIDENCE for:
- substance abuse (if anything, less likelihood for substance abuse & other high risk behaviors)

30
Q

does methylphenidate / other ADHD meds cause tic disorders?

A

no - only unmasks them / makes them more prominent

31
Q

what is the probability of childhood obesity persisting into adulthood

A

age 4 = 20%

adolescence = 80%

32
Q

risk factors for obesity

A

pre/neonatal

  • high birth weight
  • maternal diabetes
  • genetic syndromes (prader-willi, bardet-biedl, cohen syndrome)

fhx
- obese parent (esp. when <3yo)

shx
- low SES (lack of safe places for physical activity, less access to healthy foods & drinks)

33
Q

what genetic syndromes are associated with obesity?

A
  • prader-willi
  • bardet-biedl
  • cohen syndrome
34
Q

complications of obesity

A
  • OSA - cessation of breathing lasting at least 15s while sleeping (7% )
  • dyslipidemia (hyperTG, low HD) - metabolic syndrome
  • HTN (30% of kids of BMI> 95%th)
  • SCFE - at the onset of puberty in obese kids with delayed sexual maturation
  • T2DM
  • steatohepatitis (NAFLD) = mild increase in LFTs, (US) hyperechoic liver, (biopsy) fatty infiltration and fibrosis
35
Q

What complications of obesity with be reduced with weight loss

A
  • OSA
  • dyslipidemia
  • HTN
36
Q

SCFE

A

= slipped capital femoral epiphysis = displacement of femoral head from femoral neck through physeal plate

timing: at the onset of puberty in obese kids with delayed sexual maturation

sxs = antalgic gait due to pain referred to hip/thigh/knee, and limited ROM (esp. internal rotation)

xray = widened physis, sometimes obvious fracture

37
Q

what is the most prominent RF for T2DM in children?

A

obesity

average BMI of 35-39 [v. nml 15-27]

38
Q

T1 v. T2 DM

  • cause
  • presentation
  • testing
A

T1DM = insulin deficiency, d/t autoimmune destruction of pancreatic beta cells

  • weight loss
  • rare DKA
  • early childhood

T2DM = heterogeneous, with insulin resistance.

  • more indolent presentation
  • presentation: ketouria; accidental with routine screening
  • children / adult
39
Q

criteria for DM

A 
1) HbA1c >/= 6.5%
OR
2) Fasting plasma glucose >/= 126
OR
3) 2h plasma glucose >/=200 (after glucose tolerance of 75g)
4) random plasma glucose >/=200 + sxs
40
Q

screening guidelines for DM in children

A

AGE: 10yo, or onset of puberty
Overweight (BMI > BMI > 85th percentile; weight:height > 85th percentile; or weight >
120% ideal for height):

PLUS

  • Fhx T2DM in 1st/2nd degree relative
  • Ethnicity: native, african, hispanic, asian/south pacific - american
  • signs/conditions with insulin resistance(acanthosis nigricans, PCOS, HTN, dyslipidemia)
  • maternal hx of DM or GDM during pregnancy

q3y - HbA1c OR fasting glucose OR glucose tolerance

41
Q

classification of HTN in children

A

BP >120/80

<90%th == NORMAL
90-95%th == PRE-HTN
95-99%th == STAGE 1 HTN
>99%th == STAGE 2 HTN

42
Q

weight gain due to environmental factors v. underlying endocrinological disorder

A

1% of overweight pts have underlying endocrine problems

1) OBESITY = weight gain; stimulated statural growth, tall stature of age; advanced bone age; early puberty (estrogen)
2) ENDOCRINE D/O = weight gain, limited growth; short stature

43
Q

causes of elevated BP measurements

==> how to manage

A
  • “white coat” HTN ==> several BP readings in succession; school nurse to monitor
  • positioning ==> seated, relaxed, arm at level of heart (not below)
  • painful stimuli ==> correct cuff size (NOT FOR AGE)
44
Q

Causes of secondary HTN in children

A
  • placement of umbilical arterial / venous access during perinatal period ==> renal vascular dz
  • UTI ==> renal scarring ==> renal insufficiency
  • catecholamine excess (pheochromocytoma, neuroblastoma) +/- sxs of flushing, sweating, palpitations
  • Fhx renal dz +/- requiring dialysis
  • coarctation of the aorta ==> differential pulse in legs v. arms
45
Q

evaluation & management of HTN in a child

  • prehypertension
  • primary HTN
A
  • regular school nurse BP checks
  • diet - low-salt diet w/ avoidance of high/added sodium foods; intake of fresh fruits & veggies
  • screen time =2h/d; no TV in bedroom
  • moderate/vigorous physical activity >/= 60min

PREHYPERTENSION

  • dietary changes
  • f/up BP in 6mo

HYPERTENSION

  • meds for Stage 2, seondary HTN, target-organ effects
  • dietary changes
  • weight loss
  • physical activity
46
Q

initial treatment for ADHD

A
  • start med (+ dose, freq)
  • monitor for efficacy ==> via teachers + parents to report changes in behavior / possible side effects
  • additional consults w/ school psychologist for achievement
47
Q

Which of the following statements regarding stimulant medications are true? (Select all that apply.)

A Stimulant medications are addictive when used to treat children with ADHD..
B Prolonged use of stimulant medication is associated with later increased incidence of substance abuse.
C Stimulant medications may decrease appetite.
D Stimulant medications simply mask behavioral problems by sedating the child.
E Stimulant medications can cause tics.
F Patients may develop insomnia.
G Stimulant medication may cause decreased growth velocity.
H Stimulant medication leads to an increased risk of sudden cardiac death in otherwise healthy children.

A

C, F, G

48
Q

An 8-year-old boy is brought to clinic by his parents because they are concerned that he has not been doing his homework. His teacher recently called the parents to say that their son seems distracted in class, constantly interrupts other children when they are speaking, and is very fidgety. When you speak with the boy, he tells you that he did not know about the homework assignments and that he tries hard to pay attention in class. What is the next best step in management?

A Prescribe a stimulant medication for ADHD
B Suggest behavior modification for the child and parenting classes
C Group therapy for the child
D Do nothing, as this child’s behavior is normal
E Contact the teacher to find out more about his behavior. Find out more about the child’s behavior at home

A

E. Contacting the teacher to find out more about the child’s behavior at school and learning more about his behavior at home are the best ways to determine if 6 of the symptoms are present in 2 or more settings, which is required to make the diagnosis of ADHD. It also will be important to learn more about other aspects of this child’s life, as there are several factors that can lead to acting out (including learning disability, hearing disability, family stress, and abuse).

before starting meds or therapy.

49
Q

An 8-year-old healthy obese African American male with no past medical history is found to have a blood pressure of 125/90 mmHg on all four extremities on routine evaluation during an office visit for well-child care. Review of symptoms is negative. A physical exam and screening bloodwork are performed. Both are normal, with the exception of his blood pressure and obesity. What is the most likely diagnosis?

A		Primary hypertension	
B		Renal artery stenosis	
C		Coarctation of the aorta	
D		Pheochromocytoma	
E		Hyperthyroidism
A

A Given the mild hypertension and the patient’s age, symptoms are unlikely to be present. Other etiologies should be ruled out, but review of symptoms, physical examination, and laboratory studies do not suggest other etiologies.

50
Q

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?

A		Coarctation of the aorta	
B		Renal vascular disease	
C		Renal insufficiency due to renal scarring	
D		Catecholamine excess	
E		Primary hypertension
A

D
(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.

51
Q

Jane is an 8-year-old girl who presents to your clinic for follow-up after being hospitalized for status asthmaticus. She has just completed a 10-day course of systemic steroids. Given her history of moderate persistent asthma, her outpatient regimen includes Advair, a combined steroid and bronchodilator. She was also diagnosed with ADHD one year ago and was started on Concerta, 18 gm PO once a day. Her BMI today is at the 83rd percentile for her age, and her blood pressure is at the 98th percentile for her age. What is the most likely cause of her stage I hypertension?

A		Obesity	
B		The blood pressure cuff is too big	
C		Medications	
D		Renal insufficiency	
E		Neurofibromatosis 1
A

C
steroids and amphetamines can cause increases in blood pressure, especially when used in combination. Steroids increase blood pressure by mimicking endogenous cortisol and the sympathetic fight or flight response. Amphetamines mimic norepinephrine, stimulating alpha and beta adrenergic receptors, causing an overall increase in blood pressure.

Chronic drug = amphetamines

+ acute drug = steroids

==> can increase BP acute (similar to how it can pseudo-increase # of neutrophils)

52
Q

George is a 7-year-old boy frequently in trouble at school for being disruptive and inappropriately talkative in class, not following directions set by his teacher, and not working well with classmates during group activities. His mother relates that at home George is always on the go, sleeping only 6 to 7 hours a night. He does not follow her rules all the time either, including not doing his homework, and sometimes putting himself in danger by doing things she tells him not to do, such as running away unaccompanied. Which of the following is the most likely diagnosis?

A		Bipolar mood disorder	
B		Anti-social personality disorder	
C		Conversion disorder	
D		ADHD	
E		Rett syndrome
A

D. DHD is characterized by the triad of impulsivity, hyperactivity, and inattention. Other symptoms include motor impairment and emotional labiality. ADHD is typically diagnosed before the age of 7 but persists into adulthood. Intelligence is usually normal, but individuals with ADHD commonly perform more poorly academically than would be expected for their IQ.

Pediatrics (37 decks)

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