Community Pediatrics Flashcards
Definition of community pediatrics
the practice of promoting and integrating the positive social, cultural, and environmental influences on children’s health as well as addressing potential negative effects that deter optimal child health and development within a community
Goals of the routine well child visit
- Provide surveillance of growth and development
- Conduct age-appropriate evidence based screening
- Administer immunizations
- Provide anticipatory guidance
- Address parental concerns.
What are the factors that influence health outcomes, and how is the percentage distribution ?
Social , environmental and behavioral influence 50-60% of health outcomes
Genetic factors influence 30%
Health care system only 10%
What is the definition of SDH? What are these?
conditions in which people are born, grow, live, work and age
Economic stability Neighborhood and physical environment Education Food Community and social context Healthcare system
Adverse childhood experiences types
3 types:
- Abuse( physical, emotional, sexual)
- Neglecct ( physical and emotional)
- Household dysfunction
- Mental illness
- Incarcerated relative
- Mother treated violently
- Substance abuse
- Divorce
CDC-Kaiser permanent ACE study
largest investigations of childhood abuse and neglect and household challenges and later-life health and well-being.
Found that increased ACEs would lead to:
Increased morbidity and mortality
negative outcomes: alcoholism, illicit drug use, COPD, depression, fetal death, ischemic heart disease, liver disease
ACE Pyramid
Bottom to top:
- ACE
- Disrupted Neurodevelopment
- Social, emotional, cognitive impairment
- Adoption of health risk behaviors
- Disease, disability and social problems
- Early death
What do you consider when choosing a tool for screening SDH
The goals of screening in your setting( referral sources, identifying needs, social’s context)
Format used ( paper, electronic, self administered)
Who will respond to positive results
What is advocacy
to offer pubic support for or recommend a cause or policy
ITHELLPS - Screening for social determinants of health
income and food security, transportation, housing/utilities, education, legal status/immigration, literacy, personal safety and support
Four stages of growth
fetal, infant, childhood, and pubertal.
What are the MC parameters to assess growth
weight, height (or length if the child is measured supine), and head circumference.
Which growth chart to use according to age
WHO 0-2 years
CDC >2 years
Why using WHO growth chart in children < 2 years?
- utilize growth of the breastfed infant as the norm for growth.
- The WHO standards are based on high quality data collected for children younger than aged 2 years.
There is a modified CDC version for the WHO growth charts in < 2 years
The WHO growth charts as modified by CDC use the 2nd percentile and the 98th percentile as the outer most percentile cutoff values.
The use of BMI-for-age is not recommended for children younger than aged 2 years at this time
true
Factors that affect Fetal growth
- maternal nutrition
- uterine size
- hormones (including insulin and insulin-like growth factors).
Small for gestational age (SGA) definition
birth weight is below the 10th percentile for the appropriate gestational age.
SGA is different from IUGR
IUGR describes a fetus that has not reached its growth potential
Symmetric vs. Asymmetric IUGR
Symmetric - equally small, early in utero.
chromosomal abnormalities, infections
Asymmetric- spares the head, later onset
Uteroplacental insufficiency
Malnutrition
Smoking
hypertension
large for gestational age definition (LGA)
infant whose weight is greater than the 90th percentile for gestational age.
Children with ADHD often have impaired executive function including ______ and difficulty with response inhibition and control of impulsive behaviors
forward planning
abstract reasoning
working memory
mental flexibility
Comorbidities of ADHD
Oppositional defiant disorder Conduct disorder Learning disabilities Tic disorder Depression Bipolar disorder Anxiety OCD Developmental coordination disorder Substance abuse
Etiology ADHD
unclear
catecholamine metabolism in cerebral cortex appears to play a role.
other factors that may contribute: maternal alcohol, tobacco, substance
prematurity
pre and postnatal toxin exposure
FOOD DOESNT IMPACT ADHD
Diagnosis of ADHD
NICHQ Vanderbilt Assessment - parent, teacher
>= 6 of first 9 questions= inattention, above 18 yo is 5
>= 6 of second 9 questions up to 18 = hyperactivity / above 18 is 5
Ss are present in >= 2 settings
Must impair function and interfere with quality of social, school or work functioning.
and rule out other causes
Symptoms must be present before age 12 and last at least 6 months.
Diagnosis of ADHD by DMS-V Inattention dimension:
- Careless mistakes
- Difficulty sustaining attention
- Seems not to listen
- Fails to finish tasks
- Difficulty organizing
- Avoids tasks that require sustained attention
- Loses things
- Easily distracted
- Forgetful
Hyperactivity/Impulsivity dimension
Diagnosis of ADHD by DMS-V Hyperactivity/Impulsivity dimension
- Fidgety
- Unable to stay seated
- Moves excessively ( restless)
- Difficulty engaging in leisure activity quietly
- “On the go”
- “Talks excessively
- Blurts answers before questions are complete
- Difficulty awaiting turn
- Interrupts or intrudes others
In ADHD at what age does hyperactivity/impulsivity usually starts? at which age does it peak?
starts 4 years
peaks 7-8 years
In ADHD at what age does inattention becomes more apparent?
8-9 years
3 types of ADHD
- Combined presentation- inattention and hyperactivity-impulsivity were present for the past 6 months.
- Predominantly inattentive presentation- more inattentive, were present for the past 6 months
- Predominantly hyperactive-impulsive presentation- were present for the past 6 months
Differential Dx of ADHD
Sympathomimetic toxidrome hyperthyroidism absence seizure anxiety depression lead toxicity OSA (assess freq snore,breath pauses, RF) intellectual disability ( fetal alcohol syndrome, fragile X syndrome( Learning disabilities ( dyslexia) restless leg syndrome
Dyslexia
difficulty reading due to problems identifying speech sounds and learning how they relate to letters and words
MOA methylphenidate
inhibits dopamine and norepinephrine reuptake
If ss of ADHD arise suddenly suspect..
head trauma physical or sexual abuse neurodegenerative disorders mood or anxiety disorders substance abuse major psychological stress in the family or school
CRAFFT questionaire
Substance abuse
Car, Relax, Alone, Forget, Friends, Trouble
1.Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?
3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?
4. Do you ever FORGET things you did while using alcohol or drugs?
5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?
6. Have you ever gotten into TROUBLE while you were using alcohol or drugs?
CRAFFT Scoring: Each “yes” response in Part B scores 1 point.
A total score of 2 or higher is a positive screen, indicating a need for additional assessment.
Advocacy and support group for AHDH
CHADD= Children and adults with ADHD disorder
Any child who meets the criteria for ADHD should be considered a child/youth with special health care needs
True
Treatment of ADHD
- Preschool age ->behavioral therapy
* School age ->behavioral therapy + trial stimulants
Drug of choice for ADHD
Ohter drugs
Methylphenidate ( Stimulant)
Mixed amphetamine salts (Adderall)
Dextroamphetamine
Lisdexamfetamine
Dexmethylphenidate
Atomoxetine
ER guanfacine
ER clonidine
What to order before prescribing methylphenidate for ADHD?
Good PE
Evaluate if ECG is needed- this is based on physician suspicion and is not mandatory.
history of cardiac ss
cardiac family history- arrhythmias, sudden death, deathh young age.
Should treatment of ADHD be withheld if an ECG is not done?
NO, doing an ECG is not mandatory and depends on physicians judgement.
Give med for ADHD in patient with congenital heart disease?
reasonable in congenital heart disease that is either unrepaired or repaired, but without current hemodynamic or arrhythmic concerns.
Which ADHD meds increase and decrease BP and HR?
Increase: methylphenidate, amphetamine, atomoxetine
Decrese: guanfacine, clonidine
Which ADHD meds cause ECG changes?
None of the common ones.
The two meds non-FDA approved that can alter ECG:
Bupropion
Desipramine, imipramine.
Stimulant medications for ADHD can be effectively titrated every _____
3-7 days. done with the prescription note
Then face-to face visit: 4 weeks
In person visits interval to PCP once ADHD meds have been started
every month until there is a consistent optimal response.
then every 3 months in the first year of tto
Subsequent visits at depend on progress, but twice per year.
In ADHD By three years after starting medication, continue to impove even if the medication has been discontinued.
TRUE
What if you gave max dose of Methylphenidate and kid still with ADHD still not improving?
Give a med from the other stimulant grouop ( amphetamine) with similar titration plan.
Is likely that they improve
Atomoxetine black box warning
Suicidal ideation
MOA Atomoxetine
selective NE reuptake inhibitor
max response in 4-6 hours
Time of medication response in atomoxetine vs. alpha adrenergic agonists for ADHD?
atomoxetine : max response in 4-6 weeks
alpha adrenergic agonists : 2-4 weeks.
WHILE METHYLPHENIDATE IS LONGER.
AE Atomoxetine
GI symptoms Sedation early in treatment ( so prescribe half dose initially 0.5 mg/kg) appetite suppression tics headache weight loss hepatitis (rare)
Black box warning: suicidal ideation
AE alpha adrenergic agonists
somnolence
Duration of behavioral therapy
12-14 months
Which is the only FDA med approved for ADHD in children?
Dextroamphetamine,
But because there is more evidence with methylphenidate we use this one as first line.
Before prescribing ADHD med in adolescents what should you consider
substance abuse. Stop this before starting ADHD med
effect size calculation
(Treatment mean-control mean)/control SD
AE ADHD stimulants
appetite loss abdominal pain headache sleep disturbance increased BP and HR Potential to exacerbate tics - although in some improve hallucinations ( uncommon) in preschoolers: mood liability and dysphoria
** decrease growth velocity (1-2 cm) particularly if higher and more consistently doses.(effects diminished by 3rd year of tto)
Lisdexamphetamine (Vyvanse)
prodrug of dextroamphetamine
so less abusive potenital.
TIC disorders are NOT a contraindication of ADHD stimulant medications
TRUE
What to monitor in follow-up appointment of child with ADHD that has started treatment?
BP, HR Appetite weight sleep counsel about risks of substance abuse
PHQ-9 FOR DEPRESSION SCORE
Total Score Depression Severity 0-4 No or Minimal depression 5-9 Mild depression 10-14 Moderate depression 15-19 Moderately severe depression 20-27 Severe depression
Indications to admit newborn to ICU
Birth weight < 2 kg
Gestational age< 37
Inability to PO feed
Any baby who requires IVF or IV med other than ampi/genta
Any baby who is undergoing treatment for infection > 48 hrs
Any baby who received CPR and/epi during initial resuscitation or requires O2 > 60 min after birth
Any baby with thermal instability or requires thermal support
Any baby with pneumothorax; congenital heart disease that requires ongoing observation
Why Vit K is low in newborns?
Coagulation --2,7,9,10 20% of adult vit K concentration due to: poor placental transfer Immature liver with low stores Uncolonized intestine Low vit K content in breast milk.
Why we care about vit K in newborns?
Coagulation –2,7,9,10
Bleeding:
Early onset: 0-2 weeks of age
Late onset 2-12 weeks of age
manifestations may be mild: skin bruising, bleeding at umbilicus or circumcision
Severe: intestinal bleeding and fatal intracranial hemorrhage
RR for developing late VKDB is 81x among infants who do not receive IM vit K vs those who doesnt
Vit K IM vs PO
IM has been shown to prevent both early and late forms of VKDeep bleeding ( CNS, intenstine).
PO prevents early VKBD but not late, which is the most scary.
IM Vit K dose
0.5-1 mg
Dose and why do you apply Erythromycin in babies?
0.5% ophtalmic ointment within 1st hour to all babies ( including C section)
Newborns born to mom with clinical gonorrhea?
IV or IM
Asymptomatic- still at risk : single dose of ceftriaxone (25 to 50 mg/kg, up to a total dose of 125 mg IM/IV) or cefotaxime (if available; 100 mg/kg, administered IV or IM) and should be evaluated for chlamydial infection
If disseminated disease:
Treatment of disseminated infection consists of ceftriaxone (25 to 50 mg/kg per dose once daily intravenously [IV] or intramuscularly) [1,2]. The duration of treatment is 7 days for septicemia, arthritis, or scalp abscess and 10 to 14 days for meningitis [1].
Gonoccocal conjunctivitis
2-5 days
purulent conjunctivitis, with profuse exudate and swelling of the eye
if untreated: ulceration, scarring, and blindness
Dx: Thayer-Martin medium gram stain + evaluation for chlamydia
TTO single dose of ceftriaxone (25 to 50 mg/kg, not to exceed 125 mg, intravenously or intramuscularly)
