Community Pediatrics Flashcards
Why is vision screening important?
Amblyopia affects up to 5% of the population (>10 million Americans). In the first 4 decades of life amblyopia causes more vision loss than all other ocular diseases combined.
Amblyopia has a “window period” for treatment in early childhood. Screening can prevent otherwise fatal disorders such as retinoblastoma.
Refractive Errors
- Nearsighted
- Farsighted
- Astigmatism
- Anisometropia
Amblyopia
Unilateral or bilateral decrease of visual acuity caused by vision deprivation AND/OR Abnormal binocular interaction for which no organic cause can be detected. The Physician sees nothing and the Patient very little.
The eye is capable of taking the picture but the brain doesn’t recognize that there is an image.
Screen for causes of amblyopia
- Refractive errors
- Obstruction of optical pathway (e.g. cataract or corneal scar)
- Strabismus
- Other: anything that blocks input of visual information to the brain
Strabismus
Ocular misalignment
Esotropia
Eyes turn in
Exotropia
Eyes turn out
Hypertropia
One eye higher than the other
AAP standards for visual acuity
- 20/40 for children 3-5 years old
- 20/30 for 6 year old
- 20/20 for > 8 year old
Hearing Screening
Universal newborn hearing screening (UNHS) programs (false + rates: range between 2.5% and 8%). Start hearing screening at 3 years or older!
Dental referral
- Incisors erupt at approximately 6 months
- Recommend routine cleaning with soft cloth or brush with child safe toothpaste
- Fluoride varnish (1- age 6)
- Caries warrant dental referral
- Neonatal teeth
- ADA at age 1
Laboratory Screening
Most screenings are now risk based (AAP periodicity schedule)
When do we do Hemoglobin Screening?
- At 1 year (Iron deficiency anemia is more common in breastfed infants).
- If excessive milk ingestion, iron poor diet.
- Hemoglobin screening with menses
When do we do Lead Screening?
Age 1, 2 (3-6 if not previously screened, hi risk zip codes, immigrants)
What is the most common nutritional deficiency?
Iron Deficiency –Adversely affects motor & cognitive development
Iron Deficiency Anemia is most common in _______.
toddlers
Symptoms of Iron Deficiency Anemia
Abnormal sleep cycles, anemia, behavioral problems, cognitive effects
Risk Factors for Iron Deficiency Anemia
Risk factors: preterm, low birth weight birth, multiple pregnancy, iron deficiency in mother, non-‐fortified formula or cow’s milk before age 12 mo, infant diet low in iron containing foods , Children with special health needs (chronic infections or restricted diets)
Prevention and Screening for Iron Deficiency Anemia
Prevent by adequate dietary means including feeding infants iron containing cereals by 6 mo., avoiding low-iron formula during infancy and limiting cows milk in 1-5 yo. Universal screening at 12 mo age by Hb/Hct and then again at 15 mo.
Treatment for Iron Deficiency Anemia
Iron dosing, (3-‐6 mg/kg of elemental iron)
When do we start Lead Screening?
Screen @ 1 and 2 years of age
What do we see in Lead Screening?
- Elevated BLLs in children are a major preventable health problem that affects children’s mental and physical health.
- The higher a child’s BLL and the longer it persists, the greater the chance that the child will be affected.
Elevated blood Lead levels can result in:
learning disabilities, behavioral problems, mental retardation & at extremely high levels (70 µg/dL or higher), seizures, coma, and even death.
How to screen for Lead?
A VENOUS SAMPLE IS PREFERRED OVER CAPILLARY
- Fingerstick (capillary samples)
- Venous blood lead is most accurate & should confirm evel > 5 mcg/dL
- Home inspection for persistent elevated levels
Childhood Lead Poisoning Screening in Florida: Quick Reference for Medical Professionals
- Does your child live in or regularly visit (once a week or more) any house or building built before 1978?
- Does your child live in or regularly visit any house or building that has recently undergone renovation or contains vinyl mini-blinds, lead pipes, pipes with lead solder joints, or had metal pipes replaced or repaired within the last five years?
- Does your child have a mother, sibling or playmate that has or did have lead poisoning?
- Does your child frequently come into contact with an adult whose job or hobby involves exposure to lead?
• Occupations: building renovation, battery factory or recycling, auto or radiator repair, highway bridge sandblasting or painting, welding metal structures, wire cable cutting
• Hobbies: refinishing furniture, home renovation, casting bullets, auto battery or radiator repair, making stained glass, ceramics, toy soldiers, dive weights, or fishing weights - Does your child eat food or drink fluids that were stored in leaded crystal, imported ceramic, or pewter dishes?
- Does your child have contact with cosmetics, kohl, candies, spices, jewelry, ceramic dishware and home (or folk) remedies not made in the United States?
- Does your child play in loose soil, near a busy road or near any industrial sites such as a battery recycling plant, junk yard or lead smelter?
- Have you ever seen your child eat dirt or mouth on painted surfaces, paint chips, toy jewelry or vinyl mini-blinds?
- Has your child recently visited another country for an extended period of time, lived in a foster care home or in a country other than the United States?
Symptoms of Lead Poisoning
Typically asymptomatic, can lead to seizures and coma, neuropsychological deficits
Lead Levels and Their Effects
14 mcg/dL + evaluate cognitive development
45 mcg/dL + chelation of lead required
High blood levels are > 70 mcg/dL = urgent!
Prevention of Lead Poisoning
Universal lead screening at age 1 and 2, targeted screening for older kids living in communities w/ high % of old housing, or high % of kids with elevated blood lead levels
Who do we use Lipid Screening on?
Screen children older than 2yo with a + FH of dyslipidemia or premature cardiovascular disease (CVD).
Screen > 2 years to 10 yrs. if unknown FH or other CVD risk factors.
Risk Factors that need Lipid Screening
- -Overweight (BMI > 85%)
- -Obesity (BMI > 95%)
- -Hypertension (BP > 95%)
- -Cigarette smoking
- -Diabetes mellitus
How often do we screen patients for lipids?
Repeat every 3-5 years if normal
When do we start Cholesterol Screening?
ALL children cholesterol screening once between 9-11 and 17-21. Non-fasting cholesterol & HDL can be initial screening test
Cholesterol Recommendations for children that are high risk
OK to recommend low-fat or no-fat dairy at age 1 year for high risk.
Consider starting meds at age 10 for those who fail lifestyle changes (try for 6 months)
Motor Vehicle Accident/Bicycle
- Primary cause of death in US, 46% were unrestrained
- All infants and toddlers should ride in rear facing car seat until 2 years or until they reach weight/ height limits for car seats.
- After 2 yo, they can ride in forward facing car seat w/ harness until they reach 4’9 and is between 8-‐ 12 yo.
- All kids under 13 should ride in rear seats
Bike: must wear helmet
Firearms
- A gun in home double likelihood of lethal suicide attempt
- Adolescents w/history of depression or violence are at higher risk w/ gun in home
Drowning
- 2nd leading cause of injury related death in kids
- 1-‐3 yo have highest rate of drowning.
- Younger than 1 = bathtub
- 1-‐4 yo = swimming pools
- Kids/teens = large bodies of water
Fire/Burns
- Leading cause of injury related death in homes
- Smoke inhalation, flame contact, scalding, electrical, chemical, UV burns
- Scalding is most common type (1/4 from tap water)
- Hot water max is 120* for kids
- Use sunscreen, hats, sunglasses
- Don’t use sunscreen in babies under 6 mo, use sun avoidance, appropriate clothing,hats
Pediatric Fever
38.0 C or 101.4 degrees F in otherwise healthy child. Causes: LARGE differential (infection most common)
Evaluation, Treatment and Management of a Pediatric Fever
- Evaluation: H&P, laboratory studies(culture, CBC, CXR)
- Treatment: depends on etiology and patient’s age
- Management: treat the child not the fever
Treatment of Fever in Peds
Fever phobia: reassure that fevers lower than 41.7 do not cause brain damage
Acetaminophen & Ibuprofen (longer lasting)
Do not use aspirin b/c of Reye syndrome
Forms of Child Maltreatment
- Physical Abuse
- Sexual Abuse
- Emotional/Psychological Abuse
- Physical Neglect
- Emotional Neglect
- Medical Neglect
- Caregiver fabricated illness in a child (Munchausen Syndrome by Proxy)
Physical Abuse
- Any harmful action directed against a child, regardless of intent, which results in a non-accidental injury
- Most visible form of child maltreatment: from punching, beating, kicking, biting, or burning
Diagnosing Physical Abuse
THE HISTORY is crucial in differentiating abusive from accidental injury
How the History Helps Detect Abuse
- Child’s disclosure
- Unexplained injury
- Discrepant history
- –partial history
- –changing history
- –developmentally not appropriate
- –no history of behavioral change
How the History Helps Detect Abuse
- Delay in seeking medical care
- Alleged self-inflicted injury
- Alleged third-party-inflicted injury
- Repeated suspicious injuries
- Diagnostic cutaneous, eye, abdominal, brain and bone injuries
Explanations that are concerning for intentional trauma include:
- No explanation or vague explanation for a significant injury
- An important detail of the explanation changes dramatically
- An explanation that is inconsistent with the pattern, age, or severity of the injury or injuries
- An explanation that is inconsistent with the child’s physical and/or developmental capabilities
- Different witnesses provide markedly different explanations for the injury or injuries.
When is a fracture suspicious for abuse?
- No history of injury
- History of injury not plausible—mechanism described not consistent with the type of fracture, the energy load needed to cause the fracture, or the severity of the injury
- Inconsistent histories or changing histories provided by caregiver
- Fracture in a non-ambulatory child
- Fracture of high specificity for child abuse (e.g., rib fractures)
- Multiple fractures
- Fractures of different ages
- Other injuries suspicious for child abuse
- Delay in seeking care for an injury
Inadequate supervision may lead to:
- Drowning
- Poisoning
- House fires
- “Accidents” (eg, absent seat belts, smoke alarms, safe equipment, stair gates)
- Exposure to guns, domestic violence
Emotional Neglect
- Inadequate nurturance or affection
- Witness to chronic spousal abuse
- Permitted substance abuse
- Permitted maladaptive behaviors (eg, school absence, delinquency)
- Refusal or delay of mental health care
Educational Neglect
Failure to provide education as prescribed by law
Other Considerations for Neglect and Abuse
- Is there actual or potential harm?
- What is the severity of harm or risk?
- Frequency or chronicity.
- Pattern of omission of care.
Physical Neglect
- Inappropriate nutrition, clothing, hygiene
- Refusal or delay of health care
- Abandonment, leaving child alone
- Inadequate supervision
Manifestations of Neglect
Physical, Emotional and Educational
Child Protection Team
Mandated by the state (24 teams) whose goal is “To promote the safety and well being of Florida’s children by providing medically led multidisciplinary assessment services for children suspected of being abused or neglected”. The CPT responds to reports of child abuse & neglect & coordinates with staff of DCF, SO, CBC providers, and LE.
