Ch. 1 Pediatric Heath Supervision

Question 1

Normal Growth

Rules of Thumb for Expected Increase in Weight

Rules of Thumb for Expected Increase in Height

Answer 1

Question 2

Growth Disturbances = growth outside usual pattern

Two common types & their causes:

Answer 2

1. Failure to thrive (FTT) = growth rate of less than expected for a child
   
   1. Concerning with child’s weight crosses two major isobars on National Health Statistics charts
   2. May involve all growth parameters (weight*, height, head circumference [until 2 y/o], sexual maturity)
      
      1. ​Order of affected: weight, length, head circumference
   3. Most common cause of FTT:
      
      1. Inorganic FTT (i.e., disturbed parent-child bond that results in inadequate caloric intake/retention)
         
         1. Poor formula preparation, poor feeding techniques, child abuse, maternal depression, alcohol/drug use, mental illness, family violence, poverty, isolation from support systems
      2. Organic etiologies: underlying organ system pathology, infection, chromosomal disorders, systemic illness
         
         1. Determine timing of FTT (i.e., prenatal onset [intrauterine growth retardation] vs. postnatal onset of inadequate weight gain)
2. Head Growth Abnormalities = ​Microcephaly, craniosynostosis, macrocephaly
   
   1. General concepts:
      
      1. Almost all head growth occurs prenatally and during first 2 years of life
         
         1. Head circumference at birth is 25% of normal adult head size and increases to 75% of normal adult head size by 1 year of age
         2. Scalp edema (cephalohematoma) [subperiosteal hemorrhage of newborn cranium after traumatic delivery] may interfere with accurate head circumference measurements

Question 3

Head Growth Abnormalities:

Microcephaly

Craniosynostosis

Plagiocephaly

Macrocephaly

Answer 3

Microcephaly

• Head circumference is 2-3 SDs below mean for age
• Incidence is 1-2/1000 children (0.01%)
• Etiologies:
  
  • Congenital: abnormal induction and migration of brain tissue
    
    • TORCH (Toxoplasmosis, other-syphilis, rubella, CMV, HSV)
    • In utero exposure to drugs and toxins
    • Chromosomal abnormalities
  • Acquired: cerebral insult in late 3rd trimester, perinatal period, or 1 y/o
• Clinical Features:
  
  • Because head size generally reflects brain size, microcephaly is always associated with a small brain –> developmental delay + intellectual impairment
  • May be associated with: cerebral palsy/seizures

Craniosynostosis

• Premature closure of one or more of the cranial sutures
• Etiology: unknown (80-90% cases = sporadic)
• Risk factors:
  
  • Intrauterine constraint
  • Crowding
  • Metabolic abnormalities
  • Hyperthyroidism
  • Hypercalcemia
• Clinical Features:
  
  • Cranial sutures remain open until cessation of brain growth, which is 90% completed by age 2 and complete by age 5
• Diagnosis is made by physical exam of head –> usually noted by 6 mo of age / confirmed by skull radiographs and head CT scan
• Mgmt = surgical repair

Plagiocephaly = “flat head syndrome”

• Asymmetry of the infant head shape usually not associated with premature suture closure
• Most common type: positional plagiocephaly –> associated with flattening of the occiput and prominence of ipsilateral frontal area (viewed from the top, the skull is shaped like a parallelogram)
• May be associated with congenital muscular torticollis
• Mgmt: ROM exercises for associated torticollis, repositioning the head during sleep, helmet therapy, “tummy time”

Macrocephaly

• Head circumference > 95% for age
• Unlike microcephaly, size of head in patients with macrocephaly does not necessarily reflect brain size
• Etiologies:
  
  • Familial
  • Overgrowth syndromes (e.g., Sotos syndrome), in which all growth parameters are enlarged
  • Metabolic storage disorders (e.g., Canavan syndrome, gangliosidoses)
  • Neurofibromatosis
  • Achondroplasia
  • Hydrocephalus
  • Space-occupying lesions
• Evaluation:
  
  • Measure parenteral head circumferences and observe for split cranial sutures, bulging anterior fontanelle, irritability, vomiting (suggestive of inc. ICP)
  • Head U/S or CT scan to r/o hydrocephalus
  • Genetic eval if genetic syndrome suspected

Question 4

Types of Immunizations

Answer 4

1. Active immunization
   
   1. Live vaccines:
      
      1. Long-lasting immunity, but carry risk of vaccine-associated disease in recipient
         
         1. Avoid in pts with compromised immunity (e.g., cancer, congenital or drug-induced immunodeficiencies)
         2. Examples: OPV; varicella; MMR
   2. Non-live vaccines:
      
      1. Not infectious –> induce immunity for shorter periods –> thus, require boosters
      2. Examples: DTaP; hep A & B; inactivated polio (IPV); HIB; influenza; pneumococcal and meningococcal vaccines
2. Passive immunization
   
   1. Delivery of preformed antibodies to individuals who have no active immunity against a particular disease but who have either been exposed to or are at high risk for exposure to infectious agent
   2. Examples:
      
      1. VZIG for immunocompromised pts who have been exposed to varicella and are high risk for severe varicella infection;
      2. Newborns born to hep B+ mothers receive hep B IG at birth;
      3. Visitors to high-risk areas receive hep A immune globulin before travel

Question 5

Specific Immunizations:

Hep B Vaccine

Type?

Timing of vaccination?

Answer 5

Recombinant vaccine with particles of hep B surface antigen (HBsAg)

Timing: three-shot series within ~first year of life

• 1st dose HBV: Birth (within 12 hrs)
• 2nd dose: 1-2 mo.
• 3rd dose: 6-18 mo.

Question 6

Specific Immunizations:

Diphtheria, tetanus, and acellular pertussis vaccine (DTaP)

Type?

Timing of vaccination?

DTaP vs. dT

Answer 6

Type? Inactivated

Timing?

• 3 dose primary series:
  
  • 1st dose: 2 mo
  • 2nd dose: 4 mo
  • 3rd dose: 6 mo
• 2 dose secondary series:
  
  • Booster 1: 12-18 mo
  • Booster 2: 4-6 yr

dT (diphtheria and tetanus combined) contains 1/10th the dose of diphtheria toxoid and is recommended at age 11-12 and every 10 years thereafter

• Note that dT rather than DTaP is given to children > 7 y/o

Question 7

Specific Immunizations:

Oral and inactivated polio vaccines (OPV/IPV)

Advantages? Disadvantages?

Timing?

Answer 7

1. Live attenuated (OPV), administered orally
   
   1. Advantage:
      
      1. Induction of both host immunity and secondary immunity b/c it is excreted in the stool of recipient and may infect, and thus immunize, close contacts (i.e., herd immunity)
   2. Disadvantage:
      
      1. Possibility of vaccine-related polio
2. Non-live or inactivated (IPV), administered subcutaneously or IM
   
   1. Advantage:
      
      1. No vaccine-related polio
   2. Disadvantage:
      
      1. Does not induce secondary immunity

Timing: In the U.S., only IPV is now recommended

• 1st dose: 2 mo.
• 2nd dose: 4 mo.
• Booster 1: 6-18 mo.
• Booster 2: 4-6 y/o.

Question 8

Specific Immunizations:

HIB

Type of vaccine?

Timing of vaccination?

Answer 8

Type: conjugate vaccine with H. flu polysaccharide linked to various protein antigens, including diphtheria or tetanus toxoids, to augment immunogenicity

Timing of vaccination:

• Dose 1: 2 mo.
• Dose 2: 4 mo.
• Dose 3: 6 mo.
• Booster: 12-15 mo.

Question 9

Specific Immunizations:

MMR

Type of vaccine?

Timing of vaccination?

Answer 9

1. Measles: severe illness with complications that include pneumonia associated with significant mortality
2. Mumps: commonly associated with parotitis but may also cause meningoencephalitis and orchitis
3. Rubella: causes mild viral syndrome in children but may cause severe birth defects in offspring of susceptible women infected during pregnancy (TORCHeS)

Type of vaccine: live attenuated

Timing of vaccination: MMR recommended at 12-15 mo with a booster at either 4-6 years or 11-12 years of age

Question 10

Specific immunizations:

Varicella vaccine

Type of vaccine?

Timing of vaccination?

Answer 10

Type of vaccine: live attenuated vaccine

Timing of vaccination:

• 1st dose: recommended at 12-18 mo
• 2nd dose: 4-6 yo

Question 11

Specific Immunizations:

Hep A

Type of vaccine:

Timing of vaccination and recommendations:

Answer 11

Hep A

Type of vaccine: inactivated

Timing of vaccination and recommendations: 2 y/o + booster 6 mo. later for the following groups:

1. Susceptible children living in communities with high hepatitis A rates & those traveling to endemic areas
2. Individuals in other groups with high hep A rates: chronic liver disease, homosexual, bisexual men, drug users, pts with clotting factor disorders receiving blood products, pts at high risk for occupational exposure

Question 12

Specific Immunizations:

Pneumococcal vaccines (Pneumovax and Prevnar)

Answer 12

Pneumovax: composed of polysaccharide capsular antigens from 23 pneumococcal serotypes

• Major advantage:
  
  • Vaccine contains antigens from pneumococcal strains causing almost all cases of bacteremia and meningitis during childhood
• Major disadvantage:
  
  • Vaccine has little immunogenicity in children younger than 2 y/o
• Indications:
  
  • Vaccine is used primarily for older children and adults at high risk for pneumococcal disease (e.g., patients with sickle cell anemia who are functionally asplenic, immunodeficiency, chronic liver disease, and nephrotic syndrome)

Prevnar is composed of seven pneumococcal serotypes

• Major advantage:
  
  • Immunogenicity and efficacy in preventing meningitis, pneumonia, bacteremia, and otitis media from the most common pneumococcal strains in children < 2 y/o
• ​Major disadvantage:
  
  • Does not confer broad coverage against pneumococcal strains as Pneumovax
• Indications:
  
  • Vaccine recommended for all children younger than 2 y/o and for selected children older than 2 y/o who are at high risk for pneumococcal disease
  • Prevnar is recommended at 2, 4, and 6 mo. with booster at 12-15 mo.

Question 13

Adverse effects of immunization:

MMR and varicella

Answer 13

Both are live attenuated vaccines –> fever and rash may occur 1-2 weeks after immunization (i.e., after the incubation period of the virus)

Question 14

Contraindications and precautions to immunization:

a. ____________ to a vaccine or its constituents
b. _____________ within 7 days after DTaP vaccine
c. _____________ patients should not receive OPV, MMR, and varicella vaccines.
d. _____________ patients should not receive live vaccines.

Answer 14

a. Anaphylaxis to a vaccine or its constituents
b. Encephalopathy within 7 days after DTaP vaccine
c. Immunodeficient patients should not receive OPV, MMR, and varicella vaccines.
d. Pregnant patients should not receive live vaccines.

Question 15

Well Child Screening includes (8):

Answer 15

1. Complete history and physical exam
2. Growth measurements
3. Blood pressure measurements
4. Strabismus screening
5. Vision screening for ophthalmologic disoders
6. Hearing screening
7. TB screening
8. Laboratory screening
   
   1. Neonatal Metabolic (State) Screening:
      
      1. congenital hypothyroidism
      2. PKU
      3. galactosemia (all can lead to irreversible brain injury)
   2. Cholesterol and Lipid Screening:
      
      1. Recommended for children > age 2 with family hx of hypercholesterolemia, hyperlipidemia, or early MI
      2. Children with elevated cholesterol levels (75th-90th percentile) should have fasting lipid panel that includes total cholesterol, TGs, HDL, LDL
   3. Iron Deficiency Anemia Screening
   4. Urinalysis Screening
   5. Lead Screening
      
      1. ​Children < 6 y/o most susceptible to effects of lead

Question 16

Circumcision:

10% of uncircumcised males ultimately require circumcision for any of the following conditions:

Phimosis

Paraphimosis

Balanitis

Answer 16

• Phimosis
  
  • Inability to retract foreskin (normal up to age 6 but is always abnormal if ballooning of the foreskin occurs during urination)
• Paraphimosis
  
  • When retracted foreskin cannot be returned to its normal position and acts as tourniquet –> obstruction to lymphatic flow and edema –> emergent surgery for venous return
• Balanitis
  
  • Inflammation of the glans of penis
  • May be associated with Candida spp. or Gram-negative infections in infants and STis in adults

Question 17

Contraindications to circumcision

Answer 17

• Penile abnormalities (e.g., hypospadias)
• Prematurity
• Bleeding diatheses

Question 18

Pediatric Dental Care

Tooth Eruption:

Range of eruption?

What is the first tooth?

How many primary teeth and when established by?

How many secondary teeth and when established by?

Answer 18

1. Range of eruption? B/w 3-16 mo., with avg of 6 mo.
2. What is the first tooth? Lower central incisor (mandibular)
3. How many primary teeth and when established by? 20… usually by 2 y/o
4. How many secondary teeth and when established by? 32… usually by 6-8 y/o

Question 19

In dental trauma, prognosis is highest if the avulsed tooth is stored how?

Answer 19

In liquids, esp. milk

Question 20

A 4 week old boy is evaluated for macrocephaly. In addition to a head circumference > 95%, his coronal and sagittal sutures are split 1 cm and his fontanelle is bulging. Both of his parents’ head circumferences are > 95%. Which one of the following is the most likely explanation for the infant’s macrocephaly?

A. Familial

B. Achondroplasia

C. Hydrocephalus

D. Metabolic storage disorder

E. Neurofibromatosis

Answer 20

C. Hydrocephalus

This pt has signs of increased ICP, which includes split sutures and a bulging fontanelle. Other symptoms of ICP include irritability and vomiting. Hydrocephalus is the only option that is associated with increased ICP. Metabolic storage disorders, NF, achondroplasia, and familial macrocephaly are associated with enlarged head circumference but are not associated with increased ICP in a patient of this age.

Question 21

A 9-mo girl is diagnosed with iron-deficiency anemia. Her past medical hx includes an uncomplicated delivery at 38 weeks. The infant was fed with formula until 6 mo, at which time she was switched to baby foods and whole milk. Which one of the following is correct regarding her iron-deficiency anemia?

A. Her age is atypical for px of IDA.

B. Her early birth at 38 weeks gestation has led to the anemia.

C. Early introduction of cow’s milk is the likely cause of her anemia.

D. Insufficient dieatry intake of iron is the likely cause of her anemia.

E. The pt’s early introduction of solids is the likely cause of her anemia.

Answer 21

C. Early introduction of cow’s milk is the likely cause of her anemia.

Introduction of cow’s milk should occur only after 9 mo of age… early introduction = known risk factor for IDA… this is b/c cow’s milk offers less bioavailable iron and may also result in stool blood loss

Prematurity (<37 w/o) may result in lower iron stores with resultant anemia

Question 22

A 1 y/o child living in an apt with old chipping paint is suspected of being at high risk for lead intoxication. Which of the following findings on a routine health maintenance visit would support this diagnosis?

A. FTT

B. Anemia

C. Fluorosis

D. Microcephaly

E. Impaired hearing

Answer 22

B. Anemia

Lead intoxication may cause a variety of clinical manifestations, including neurocognitive impairment, lethargy, anemia, vomiting, and irritability. Most patients exposed to lead, however, are asymptomatic. Fluorosis is not associated with lead exposure, and lead exposure has not been known to result in microcephaly, FTT, or hearing impairment.

Question 23

On a routine health maintenance visit, a 9 mo infant is noted to have normal growth and development, and an unremarkable physical exam. Which of the following should be included in your counseling of the parents at this time?

A. Vitamin D supplementation should be initiated if the pt has minimal exposure to sunlight.

B. The patient should be encouraged to begin using a walker to stimulate gross motor development.

C. The infant should now be placed in a forward-facing car seat.

D. Toilet training should be initiated.

E. Eggs and fish may now be introduced into the infant’s diet.

Answer 23

A. Vitamin D supplementation should be initiated if the pt has minimal exposure to sunlight.

^ will prevent development of rickets in first year of life

Infant walkers are not recommended b/c of risk of injury associated with their use.

Infants should be placed in a rear-facing car seat until they are 12 mo and weigh 20 lbs.

Toilet training generally initiated between 1-2 y/o.

B/c of risk of allergy, fish, egg whites, wheat, citrus fruits, nuts, chocolate avoided until at least 1 y/o.

Question 24

An HIV+ patient presents 24 hrs after being exposed to varicella, with no prior hx of chicken pox, nor any record of having received the varicella vaccine.

What is the most appropriate type of immunization indicated at this time?

Answer 24

Passive immunization is indicated.

An immunocomproised pt, such as a child with HIV, exposed to varicella, would be at high risk for acquiring a severe varicella infection and should therefore receive VZIG (an example of passive immunization), ideally within 96 hrs of exposure to the disease.