Development Flashcards

Question 1

Q

Average birth weight is ___kg (7lb 5oz; normal range 2.72-4.54kg (6-10lb)), average length is ___cm (20in; normal range 47-54.6cm (18.5-21.5in)), and average HC is __cm (13.8in, normal range 33-37cm (13-14.6in)).

Answer

A

Average birth weight is 3.32kg (7lb 5oz; normal range 2.72-4.54kg (6-10lb)), average length is 50.8cm (20in; normal range 47-54.6cm (18.5-21.5in)), and average HC is 35cm (13.8in, normal range 33-37cm (13-14.6in)).

Question 2

Q

Weight

2x BW by _mo
3x BW by __mo
4x BW by __mo

Answer

A

Weight

2x BW by 4mo
3x BW by 12mo
4x BW by 24mo

Question 3

Q

Normal weight gain
- ___g/day (1oz/day; 1kg or 2lb/mo) from 0-3mo
- ___g/day (1oz q2days; 0.6kg or 1lb/mo) from 3-6mo
- ___g/day (1oz q3days; 0.5kg/mo) from 6-12mo
- __kg per year from 2yo-puberty

Answer

A

Normal weight gain
- 20-30g/day (1oz/day; 1kg or 2lb/mo) from 0-3mo
- 15-20g/day (1oz q2days; 0.6kg or 1lb/mo) from 3-6mo
- 10-15g/day (1oz q3days; 0.5kg/mo) from 6-12mo
- 2kg/5lb per year from 2yo-puberty

Question 4

Q

Head circumference

0-2mo (fastest): 0.___cm/week (___cm/month)
2-6mo: 0.___cm/week
6-12mo: ___cm total

Answer

A

Head circumference

0-2mo (fastest): 0.5cm/week (2cm/month)
2-6mo: 0.25cm/week
6-12mo: 3cm total

Question 5

Q

Brain is __% of adult size by 1 year old, __% of adult size by 3 years old, __% of adult size by 7 years old

Answer

A

Brain is 75% of adult size by 1 year old, 80% of adult size by 3 years old, 90% of adult size by 7 years old

Question 6

Q

Height
- Length increases by _% by 1yo, _ by 4yo, and _ by 13yo.

0-1yo: __cm/year (_in)
1-2yo: __cm/year (_in)
2-4yo: __cm/year (_in)
4yo - puberty: __cm/year (_in)
- less than __ in/year is concerning

Answer

A

Height
- Length increases by 50% by 1yo, doubles by 4yo, and triples by 13yo.

0-1yo: 25cm/year (10in)
1-2yo: 12cm/year (25/2) (4in)
2-4yo: 8cm/year (25/3) (3in)
4yo - puberty: 5-6cm/year (2in)
- <2 in/year is concerning

Question 7

Q

Puberty
- Girls: Begins at 9.5yo with average peak height velocity of __cm/year at __yo when girls are at SMR 2-3 approx 6mo before menarche
  - Girls are approx 10cm shorter than boys at IGS
- Boys: Begins at 11.5yo with PHV __cm/year at ___when SMR -.

Answer

A

Puberty
- Girls: Begins at 9.5yo with average peak height velocity of 9cm/year at 11.5yo when girls are at SMR 2-3 approx 6mo before menarche
  - Girls are approx 10cm shorter than boys at IGS
- Boys: Begins at 11.5yo with PHV 10.3 cm/year at 13.5 when SMR 3-4.

Question 8

Q

Upper body segment/Lower body segment (U/L) ratio

Ratio decreases from birth and reaches lowest point during early puberty
- Infant: 1.7
- 3yo: 1.3
- 10yo: 1
- Nadir during early puberty
- Adult: 0.9-1.0
Increased U/L ratio (longer trunk, shorter legs): Turner syndrome, skeletal dysplasias of long bones (achondroplasia), or patients with precocious puberty
Decreased U/L ratio for age: May be associated with skeletal dysplasia involving the spine and disorder involving delayed/incomplete puberty (Klinefelter, Marfan, Kallmann syndromes).

Answer

A

Upper body segment/Lower body segment (U/L) ratio

Ratio decreases from birth and reaches lowest point during early puberty
- Infant: 1.7
- 3yo: 1.3
- 10yo: 1
- Nadir during early puberty
- Adult: 0.9-1.0
Increased U/L ratio (longer trunk, shorter legs): Turner syndrome, skeletal dysplasias of long bones (achondroplasia), or patients with precocious puberty
Decreased U/L ratio for age: May be associated with skeletal dysplasia involving the spine and disorder involving delayed/incomplete puberty (Klinefelter, Marfan, Kallmann syndromes).

Question 9

Q

Requirements

Premature:
- Kcal: ___ kcal/kg/day
- Protein: Infants <1200g require ___g/kg/day; >1200g require 3.5-4g/kg/day
- Fat: 4-___ kcal/kg/day
- Carbs: 12-14 kcal/kg/day
Term Infants
- Kcal: ____ kcal/kg/day
- Protein: 1.5 g/kg/day
- Fat: 3.3-5 kcal/kg/day
- Carbs: 10 kcal/kg/day
Early childhood
- Kcal: 1000 kcal/day to 1200-1400 kcal/day
- Protein: 1 g/kg/day
- Fat: 13 g/day up in 1-3yo to 19g/day in 4-8yo
- Carbs: 130g/day
Adolescents:
- Kcal: 1800-2200 kcal/day
- Protein: 1 g/kg/day
- Carbs: 130 g/day
Adults:
- Protein: 0.8g/kg/day

Answer

A

Requirements

Premature:
- Kcal: 120 kcal/kg/day
- Protein: Infants <1200g require 4g/kg/day; >1200g require 3.5-4g/kg/day
- Fat: 4-7 kcal/kg/day
- Carbs: 12-14 kcal/kg/day
Term Infants
- Kcal: 100 kcal/kg/day
- Protein: 1.5 g/kg/day
- Fat: 3.3-5 kcal/kg/day
- Carbs: 10 kcal/kg/day
Early childhood
- Kcal: 1000 kcal/day to 1200-1400 kcal/day
- Protein: 1 g/kg/day
- Fat: 13 g/day up in 1-3yo to 19g/day in 4-8yo
- Carbs: 130g/day
Adolescents:
- Kcal: 1800-2200 kcal/day
- Protein: 1 g/kg/day
- Carbs: 130 g/day
Adults:
- Protein: 0.8g/kg/day

Question 10

Q

Failure to thrive

One point on the growth curve:
- Weight less than __%ile
  - Weight for height less than __%ile
  - Weight 20% below ideal weight for height
A series of points on the growth curve
- Weight gain <20g/day from 0-3 months of age
- Weight gain <15g/day from 3-6 months of age
- Downward crossing of >2 major percentiles

Answer

A

Failure to thrive

One point on the growth curve:
- Weight <3%ile
- Weight for height <5%ile
- Weight >20% below ideal weight for height
A series of points on the growth curve
- Weight gain <20g/day from 0-3 months of age
- Weight gain <15g/day from 3-6 months of age
- Downward crossing of >2 major percentiles

Question 11

Q

Car Seats

Rear-facing car seat: Until at least ___yo or max height or weight limit for car seat (at least __lb)
Forward-facing car seat: Until at least __yo and at least ___lb
Booster seat: Until ___” in height and are ___yo
Rear seat with seat belt: Until ___yo

Answer

A

Car Seats

Rear-facing car seat: Until at least 2yo or max height or weight limit for car seat (at least 20lb)
Forward-facing car seat: Until at least 5yo and at least 40lb
Booster seat: Until 4’9” or 57” in height and are 8-12yo
Rear seat with seat belt: Until 13yo

Question 12

Q

Breastfeeding

Contraindications by mother
- HTLV-, HTLV-2
- Untreated brucellosis
- HIV
- HSV on affected breast
- Ebola
- CMV
- Isotretinoin therapy
- Drugs: Amphetamines, chemotherapy agents, ergotamines, statins
- Radioactive medications
- Substance abuse
- Alcohol abuse
- May provide expressed milk:
  - _____
  - _____
  - _____
NOT contraindications:
- Shingles/herpes zoster
- Gadolinium-based contrast
- Long-term opiate replacement maintenance therapy
- Hepatitis BsAg positive
- HCV infection

Answer

A

Breastfeeding

Contraindications by mother
- HTLV-, HTLV-2
- Untreated brucellosis
- HIV
- HSV on affected breast
- Ebola
- CMV
- Isotretinoin therapy
- Drugs: Amphetamines, chemotherapy agents, ergotamines, statins
- Radioactive medications
- Substance abuse
- Alcohol abuse
- May provide expressed milk:
  - Active, untreated TB
  - H1N1 influenza
  - Varicella developed 5 days before to 2 days after delivery
NOT contraindications:
- Shingles/herpes zoster
- Gadolinium-based contrast
- Long-term opiate replacement maintenance therapy
- Hepatitis BsAg positive
- HCV infection

Question 13

Q

Iron

Full term infants require __mg/kg of elemental iron starting at ___mo until iron-rich complementary foods are consumed
Preterm infants require __mg/kg of iron/day starting at __mo until 12mo

Answer

A

Iron

Full term infants require 1mg/kg of elemental iron starting at 4-6mo until iron-rich complementary foods are consumed
Preterm infants require 2mg/kg of iron/day starting at 1mo until 12mo

Question 14

Q

Learning Disability

Measures of Cognitive/Aptitude and Adaptive skills have a mean of __ and a standard deviation of __. Achievement scores are generally within __ SD (__ points) of cognitive scores.
- Aptitude/Cognition: ____
- Achievement: ____
Definition
- 1) ______
- 2) ______
- 3) Student’s failure to respond to evidence-based educational interventions.
Unlike ID which requires deficits in both intellectual functioning and adaptive functioning, level of ____ functioning is not a diagnostic criterion for LD.

Answer

A

Learning Disability

Measures of Cognitive/Aptitude and Adaptive skills have a mean of 100 and a standard deviation of 15. Achievement scores are generally within 1 SD (15 points) of cognitive scores.
- Aptitude/Cognition: Verbal IQ, performance IQ, full-scale IQ
- Achievement: Reading, math, writing
Definition
- 1) Significant discrepancy between intelligence (aptitude or IQ tests) and achievement (achievement tests). The level of significance is a difference of 1-2 SDs.
- 2) Low achievement in a child with at least low-average cognition. Achievement score is >1.5 SD below the mean in the setting of at least average cognition (IQ score within 1 SD of mean)
- 3) Student’s failure to respond to evidence-based educational interventions.
Unlike ID which requires deficits in both intellectual functioning and adaptive functioning, level of adaptive functioning is not a diagnostic criterion for LD.

Question 15

Q

Intellectual Disability (>__yo) (less than ___yo is global developmental delay)

Significant impairment in both cognitive abilities (>2 SDs below mean) and adaptive functioning are required for diagnosis of intellectual disability.
- Adaptive skill impairment is as important as a low IQ
- Score > ___ SDs below the population mean (<70 points) in_____ AND ______.
  - Normal: 1 SD; score of 85-115
  - Mild: 2-3 SDs; score of 55-70 (majority 85% of those with ID)
  - Moderate: 3-4 SDs; score of 40-55
  - Severe: 4-5 SDs; score of 25-40
  - Profound: >5 SDs; score <25
Prognosis
- Mild ID: Up to ____th grade level. Adults with mild ID can live and work independently with some possible need for intermittent support.
  - limited understanding of risk in social situations, and have poor social judgement
- Moderate ID: Up to the ____rd grade level, but as adults, will require support and supervision for work and daily living
- Severe ID: Children w severe ID are typically identified in the first few years after birth due to delays in motor and language development. They require assistance and supervision for their self-care, daily needs, and safety during childhood and adulthood. Sheltered work may be possible with ongoing assistance
- Profound ID: dependent on others for personal care and activities of daily living; needs nursing care; typically not employable

Answer

A

Intellectual Disability (>5yo) (<5yo is global developmental delay)

Significant impairment in both cognitive abilities (>2 SDs below mean) and adaptive functioning are required for diagnosis of intellectual disability.
- Adaptive skill impairment is as important as a low IQ
- Score > 2 SDs below the population mean (<70 points) in both Cognitive/Aptitude (IQ) AND Adaptive measures are in the ID range.
  - Normal: 1 SD; score of 85-115
  - Mild: 2-3 SDs; score of 55-70 (majority 85% of those with ID)
  - Moderate: 3-4 SDs; score of 40-55
  - Severe: 4-5 SDs; score of 25-40
  - Profound: >5 SDs; score <25
Prognosis
- Mild ID: Up to 6th grade level. Adults with mild ID can live and work independently with some possible need for intermittent support.
  - limited understanding of risk in social situations, and have poor social judgement
- Moderate ID: Up to the 3rd grade level, but as adults, will require support and supervision for work and daily living
- Severe ID: Children w severe ID are typically identified in the first few years after birth due to delays in motor and language development. They require assistance and supervision for their self-care, daily needs, and safety during childhood and adulthood. Sheltered work may be possible with ongoing assistance
- Profound ID: dependent on others for personal care and activities of daily living; needs nursing care; typically not employable

Question 16

Q

Tracks horizontally past midline
Neck control, lift head to 45 degrees
Holds hands at midline
Social smile
Cooing

Answer

A

2mo

Tracks horizontally past midline
Neck control, lift head to 45 degrees
Holds hands at midline
Social smile
Cooing

Question 17

Q

Lift head

- Can bring hands to mouth

Answer

A

3mo

Lift head
Can bring hands to mouth

Question 18

Q

Lift head up to 90 degrees and chest when prone. Prop up on FOURarm (FOREarm)
Rolls Front to back (shoulder control)
Hands predominantly open. Voluntary grasp
Smiles at mirror

Answer

A

4mo

Lift head up to 90 degrees and chest when prone. Prop up on FOURarm (FOREarm)
Rolls Front to back (shoulder control)
Hands predominantly open. Voluntary grasp
Smiles at mirror

Question 19

Q

Lift up using hands
Sitting up with support (pelvic control), rolling back to front (abdominal control). Support weight with legs
Transfer objects from hand to hand.
Place hands on bottle/breast (longer than briefly grasping)
Recognize familiar persons
Recognize own name
Babbling
Stranger anxiety

Answer

A

6mo

Lift up using hands
Sitting up with support (pelvic control), rolling back to front (abdominal control). Support weight with legs
Transfer objects from hand to hand.
Place hands on bottle/breast (longer than briefly grasping)
Recognize familiar persons
Recognize own name
Babbling
Stranger anxiety

Question 20

Q

sit without support

Answer

A

7mo - sit without support

Question 21

Q

joint attention. Hold a bottle

Answer

A

8mo - joint attention. Hold a bottle

Question 22

Q

Crawls, Pull to stand, Cruise along furniture (upper leg control)
Immature pincer grasp (thumb and index finger)
Says mama and dada. Repetitive responding

Answer

A

9mo

Crawls, Pull to stand, Cruise along furniture (upper leg control)
Immature pincer grasp (thumb and index finger)
Says mama and dada. Repetitive responding
Object permanence. Pat a cake, peek a boo.

Question 23

Q

Object permanence. Pat a cake, peek a boo.

Answer

A

9mo

Crawls, Pull to stand, Cruise along furniture (upper leg control)
Immature pincer grasp (thumb and index finger)
Says mama and dada. Repetitive responding
Object permanence. Pat a cake, peek a boo.

Question 24

Q

Wave bye bye

Answer

A

10mo

- Wave bye bye

Question 25

Q

Independent steps (lower leg/foot control)
Mature pincer grasp
Shows objects to share interest
At least 1 single word. Use mama and dada specifically
Protoimperative pointing (gestures/pointing to an object to obtain)
1 step command with gestures. Responds to own name.

Answer

A

1yo

Independent steps (lower leg/foot control)
Mature pincer grasp
Shows objects to share interest
At least 1 single word. Use mama and dada specifically
Protoimperative pointing (gestures/pointing to an object to obtain)
1 step command with gestures. Responds to own name.

Question 26

Q

protodeclarative pointing (point to express interest)

Answer

A

14mo - protodeclarative pointing (point to express interest)

Question 27

Q

Can climb on furniture, can stoop to pick up object, turn pages in book

Question 28

Q

3-5 words, greets people

Question 29

Q

Points to 1 body part

Question 30

Q

Starts to show empathy

Question 31

Q

Shared attention

- Understand 1 step commands with no gesture

Question 32

Q

Scribbles

- Build tower of 2 cubes

Question 33

Q

Runs well
Uses 10-25 words
Between words and sentences
Points to 3 body parts
Uses cup well. Begins to use spoon
Stacks 4 blocks - to get an approx estimate of the number of blocks a child should stack, multiple age in years x ___ and round to the nearest even number)
Hand dominance prior to ___mo is abnormal and “red flag”

Answer

A

18mo (rule of halves)

Runs well
Uses 10-25 words (18 is halfway between 10-25)
Between words and sentences
Points to 3 body parts (cutting the 8 in half to make 3)
Uses cup well. Begins to use spoon
Stacks 4 blocks (half of 8 Is 4) - to get an approx estimate of the number of blocks a child should stack, multiple age in years x 3 and round to the nearest even number)
Hand dominance prior to 18mo is abnormal and “red flag”

Question 34

Q

2 Words sentences, Follows 2-step commands, 50 words, 50% understandable. 6 cubes. identifies 6 body parts.
Steps with both feet on each step, jumps with 2 feet, kick ball, throw overhand, wash and dry hands
“I,” “me”
Imitate vertical and horizontal lines
Parallel play

Answer

A

2yo

2 Words sentences, Follows 2-step commands, 50 words, 50% understandable. 6 cubes. identifies 6 body parts.
Steps with both feet on each step, jumps with 2 feet, kick ball, throw overhand, wash and dry hands
“I,” “me”
Imitate vertical and horizontal lines
Parallel play
18-24 months have mastered object permanent and flexibility in problem solving due to the development of a complex understanding of cause and effect

Question 35

Q

Walks up stairs with alternating feet

Question 36

Q

8-cube tower

Question 37

Q

Brushes teeth with assistance

Question 38

Q

3-5 words sentences, follow 3-step directions, speech ¾ intelligible, knows 3 pieces of information (first name, age, gender)
Pedals tricycle, builds 3-cube bridge

Question 39

Q

Can count up to 3 objects, can repeat 3 numbers forward.

Question 40

Q

Balance on 1 foot for 2-3 seconds

Question 41

Q

Draw circle (pi = 3.14). Ability to share independently without prompting.

Question 42

Q

Draws a person with head and 1 other body part

- Wiggle thumbs

Question 43

Q

Dresses self without help

Question 44

Q

Cooperative play.

Question 45

Q

Converses, speech 100% intelligible, Name 4 colors. Counts to 4.
Proficient in 4 Ps (pronouns, prepositions, plurals, past tense).
Draw cross. Catch bounced ball. Ability to label simple emotions.

Question 46

Q

Hopping on 1 foot 2-3x/galloping, balance on 1 foot for (4-8) 10 sec.

Question 47

Q

Uses a fork

Question 48

Q

Down stairs alternating feet

Question 49

Q

Draws Square

Question 50

Q

Brushes teeth alone

Question 51

Q

S kips. 5 word sentences.
Extended narrative, future tense
Knows 5 pieces of information (some letters, some numbers, shapes, full name, address).

Question 52

Q

Reads 25 words.

Question 53

Q

Hop on 1 foot 15x.
- Walks backwards heel-toe.
- Jumps backwards.

Question 54

Q

Writes first name.
- Draw triangle
- Cuts with scissors
- Spread with knife.

Question 55

Q

Names 10 colors.
- Counts 10 objects.
- Counts to 10.
- Draws 10 part person.

Question 56

Q

Knows right and left.

- Understands opposites

Question 57

Q

tie shoes, ride bike. Ability to distinguish fantasy from reality

Children may understand there are rules but may have a hard time controlling impulses.

Answer

A

6yo

At 6yo, children may understand there are rules but may have a hard time controlling impulses. By 8yo, children have developed a conscience and are aware of social expectations and rules.

Question 58

Q

Reads 250 words.

- Repeat 8-10 word sentences

Question 59

Q

Copy a diamond
- Draw 12-14 part person.
- Ties shoes.

Question 60

Q

One point is credited for each: 2 eyes, 2 ears, nose, mouth, hair, 2 arms, 2 legs, 2 hands, 2 feet, a neck, and a trunk. Each point converts to a value of ___ added to a base of __.

Answer

A

One point is credited for each: 2 eyes, 2 ears, nose, mouth, hair, 2 arms, 2 legs, 2 hands, 2 feet, a neck, and a trunk. Each point converts to a value of ¼ added to a base of 3.

Question 61

Q

Early adolescence (_-_yo): Preoccupation with \_\_, formation of \_\_-sex peer groups.
- \_\_\_ cognition

Answer

A

Early adolescence (10-13yo): Preoccupation with SELF, formation of same-sex peer groups.
- Concrete cognition

Question 62

Q

Middle adolescence (\_\_-\_\_yo): \_\_\_ group. Move from concrete to \_\_\_ thought. Separation from family. Conflict within family peaks.
- Feeling of\_\_\_\_

Answer

A

Middle adolescence (14-17yo): PEER group. Move from concrete to abstract thought. Separation from family. Conflict within family peaks.
- Feeling of omnipotence and immortality

Question 63

Q

Late adolescence (\_\_-\_\_yo): \_\_\_\_ relationships. Completion of a separate identity from parents.
- \_\_\_\_

Answer

A

Late adolescence (18-21yo): Individual relationships. Completion of a separate identity from parents.
- Idealistic

Question 64

Q

Vegetarians

- Supplements needed: __, __, __, __

Answer

A

Vegetarians

- Supplements needed: Vitamin B12, Iron, Calcium, Zinc

Answer 35

A

Vitamin A deficiency

Pt:
- Impaired adaptation to darkness (night blindness), dry conjunctiva (xerophthalmia/ xerosis conjunctiva)
- Bitot spots (keratinization of the cornea)
- Progress to dry cornea (xerosis cornea)

Answer 36

A

Hypervitaminosis A

- Increased ICP, hypercalcemia

Answer 37

A

Vitamin C (Ascorbic acid) Deficiency (Scurvy)

Path
- 1. Poor consumption of foods
- 1. Consumption of overly heated foods. Classic is consumptions of evaporated boiled milk in infants
- 1. Medical conditions resulting in decreased stores
Pt:
- Fatigue and lethargy, corkscrew-coiled hairs / perifollicular keratosis that progresses to hemorrhage
- Delayed wound healing and bleeding (gum inflammation and hemorrhage is classic)
- Scurvy: Bone pain, joint hemorrhage, arthropathy
  - Osteopenia is very common with radiographic changes
Labs: Mild normochromic, normocytic anemia secondary to iron deficiency, folate deficiency, bleeding, and hemolysis
XR: Wimberg and Frankel lines, white dense lines around the growing metaphysics and epiphysis respectively, are rarely seen but are specific to scurvy.
Dx: Clinical. Assess body stores of vitamin C with leukocyte ascorbic acid level.
Tx: 100-300mg daily of vitamin C in children for 1mo

Answer 38

A

Vitamin E (alpha-tocopherol) deficiency

Pt with pancreatic dysfunction (such as CF population) are at risk
Pt:
- Neurologic dysfunction, progressive ataxia, deceased DTRs, generalized weakness, visual changes
- Hemolytic anemia with elevated relic and hyperbilirubinemia

Answer 39

A

\Vitamin B1 (Thiamine) deficiency

Dry beriberi - peripheral neuropathy
Wet beriberi - neuropathy in addition to cardiac failure
Wernicke encephalopathy - ophthalmoplegia, ataxia, and confusion

Answer 40

A

Vitamin B2 (Riboflavin)
- Cheilosis, sore tongue

Answer 41

A

Vitamin B3 (Niacin) Deficiency - Pellegra
- Pt: Diarrhea, dermatitis, dementia

Answer 42

A

Vitamin B12 (Cobalamin) Deficiency

Path: Strict vegetarian or vegan diets. Ileal disease. Pernicious anemia, Pancreatic insufficiency
Pt:
- Peripheral neuropathy, hypotonia, developmental delay, failure to thrive
Labs:
- Macrocytosis and hypersegmented neutrophils
- Methylmalonic acid and total homocysteine levels are often markedly elevated.

Answer 43

A

Folate deficiency

Path:
- Can result from inadequate dietary intake, increased metabolic demand (eg infancy, pregnancy, lactation), malabsorption, or metabolic interference (eg methotrexate, sulfonamide).
- Consumption of a diet high in goat milk, which is low in folic acid
  - Goat milk is a poor source of folate and results in megaloblastic anemia in unsupplemented infants if used as the sole food.
Tx: 1-5 mg daily.
- If patient has concomitant vitamin B12 deficiency, use high-dose folate can correct RBC problems but worsen neurologic manifestations of B12 deficiency. It is therefore important to determine if B12 deficiency is also present.

Answer 44

A

Vitamin K (Phylloquinone) deficiency

Pt:
- 1. Early (within 24 hours after birth): Presents with 24 hours of life with cephalohematoma, intra-abdominal hemorrhage, and/or intracranial bleeding
- 1. Classic (2-7 days); Occurs in infants, from day 2-7 of life with umbilical cord bleeding, GI hemorrhage, or oozing from puncture sites
- 1. Late (2 weeks - 6mo): presents from ages 2-12 weeks
Labs: Mildly prolonged PT and PTT

Answer 45

A

Zinc deficiency

Path:
- Micronutrient/trace mineral deficiency is a long-term adverse effect of bariatric surgery without appropriate supplementation
- Lost in stool: Deficiency can occur in any chronic diarrhea
Pt:
- Mild: Taste (hypogeusia) and smell impairment, night blindness, and depressed immunity.
- Severe: Alopecia, bullous pustular dermatitis, diarrhea, and frequent infections due to a depressed immune system
Acrodermatitis enteropathica - see
Tx: 1-3 mg/kg/day PO elemental zinc

Answer 46

A

Subcutaneous: MMR, varicella, MMRV

Answer 47

A

Streptomycin, neomycin, polymyxin B: IPV

Answer 48

A

Neomycin: MMR, varicella, some diphtheria, tetanus, acellular pertussis (DTaP), hepatitis A, influenza, rabies

Answer 49

A

Gelatin: Influenza, MMR, varicella, MMRV, yellow fever, oral typhoid, rabies

Answer 50

A

Casein: DTap, Tdap (immunize and observe if severely milk allergic)

Answer 51

A

Egg allergy is NOT a contraindication to the MMR vaccine. Neither premedication nor prolonged monitoring after vaccination is necessary.

Answer 52

A

Yellow fever: is contraindicated in individuals with hypersensitivity to eggs or chicken proteins. Skin-prick testing be performed before administering

Answer 53

A

Inactive influenza vaccine: Egg allergy is not a contraindication to IIV (IM inactivated influenza vaccine), and numerous studies have confirmed its safe administration. Current guidelines recommend vaccinating egg-allergic individuals in a medical setting with appropriate staffing and resources to tx an allergic reaction and monitoring of these patients for 30 mins after vaccine administration.
- Intranasal live attenuated vaccine (LAIV) and intramuscular inactivated influenza vaccine (IIV) are cultured in fluid derived from chicken embryos.

Answer 54

A

Live vaccines: BCG, OPV, MMR, varicella, intranasal influenza, rotavirus, smallpox, yellow fever

Answer 55

A

Do not give live virus or live bacterial vaccines to children with congenital immune dysfunction, receiving immunosuppressive therapy, or undergoing BMT
Do NOT give OPV to household contacts of these children bc the vaccine strain can be transmitted in the household to the immunocompromised child.
IN influenza virus vaccine is live and poses a risk fo severely immunodeficient patients
Do NOT given live virus or bacterial vaccines to a child receiving >2 mg/kg of prednisone, either daily (total 20mg) or every other day, for >14 days. Child should be off steroids for at least 3 mo before you give these vaccines
No live vaccines during chemo. Wait for 3 mo after completion
Children with HIV receive MMR and varicella vaccines at 12mo of age unless they are severely immunocompromised. Do NOT give OPV to children with HIV.

Answer 56

A

Influenza

There is a small increased risk for febrile seizures during the 24 hours after simultaneous administration of trivalent IIV and the PCV13 vaccine. The same holds true with simultaneous administration of IIV and the DTaP vaccine. Therefore, caution parents regarding this potential risk.
Children age 6 months through 9 years should receive a 2 doses separated by at least 4 weeks during the 1st flu season

Answer 57

A

Hepatitis B virus
- Typical schedule is at birth, at 1-2 months, and at 6 months.

When the mother is HBsAg-, the initial hepatitis B vaccine can be given within the first 2 mo. However, the AAP recommends that hospitals have policies in place to ensure administration of the 1st dose of HepB should be given prior to discharge to all infants >2kg at birth
If maternal hepatitis B surface antigen positive HBsAg+, baby must get Hep B Ig and Hep B vaccine <12 hours after birth.
- if <2kg, 1st dose does not count toward the 3 doses. 3 additional doses should be given at 1, 2-3, and 6mo of age or 2, 4, and 6 months of age
- If >2kg- 2nd and 3rd doses should be given at 2 and 6 mo of age
If maternal hepatitis B status is unknown, baby should get Hep B vaccine < 12 hours after birth and check mom’s HBsAg. HBIG can be deferred until maternal results become known.
- If infant weight is >2000g, HBIG be given by 7 days of life (or hospital discharge if sooner) if mother remains HBsAg unknown or is found to be positive.
- If infant weight is <2000g, HBIG would need to be given within 12 hours of delivery if the mother remained HBsAg unknown or was found to be positive.

Answer 58

A

Rotavirus

Only live vaccine administered prior to 1yo
The 1st dose must be administered from 6 weeks through 14 weeks 6 days of age. All doses must be completed by 8mo and 0 days.
Contraindications to vaccine:
- Hx of intussusception: Increasing risk of intussusception with age is the reason for maximum age restrictions
- SCID
- Anaphylaxis allergy to latex (oral applicator for rotarix vaccine contains natural latex rubber)

Answer 59

A

HPV Vaccine

Recommended time for first dose is 11-12yo, but HPV vaccine can be started at age 9
If initiated <15yo (9-14yo), need 2 vaccines separated by 6-12 months.
If start the series >15yo, need 3 vaccines administered at 0, 1-2 months after the first, and 6 months after the first

Answer 60

A

DTaP

5 doses prior to 7yo: At 2mo, 4mo, 6 mo, 15-18mo, at 4-6 yrs (5th dose can be skipped if 4th dose given after age 4).
DTaP is for those <7 years.
For >7yo, use Tdap
For children >7yo who are unimmunized or who have not completed the DTaP series the 1st dose in the catch-up series should be Tdap.
- In children 7-10yo who require a dose of Tdap to catch up from an incomplete DTaP series, the 11-12yo dose of Tdap can be waived.
Absolute CI to pertussis-containing vaccines:
- Anaphylaxis following a previous vaccination
- Encephalopathy within 7 days of receipt
- Progressive neurologic disorder, infantile spasms, uncontrolled epilepsy, progressive encephalopathy, developmental delay of unknown etiology
Precautions:
- Guillain-Barre syndrome within 6 weeks after a previous tetanus toxoid-containing vaccine
- Moderate-severe acute illness with or without a fever (until resolution)
In previously unimmunized children 1-6 yo with a medical contraindication to a pertussis-containing vaccine, administer 2 doses of DT approximately 2 months apart, followed by a 3rd dose in 6-12 months to complete the initial series.

Answer 61

A

MMR

Absolute CI:
- Anaphylaxis to prior MMR vaccination or to neomycin or gelatin
- Severe Immunodeficiency: cancer, blood dyscrasia, acquired immunodeficiency, on immunosuppressive therapy
  - Exception: HIV-infected children should receive MMR in the absence of severe immunosuppression, defined as CD4 >15% for >6 mo for persons <5 yo; CD4 >15% and/or CD4 count >200 lymphocytes/uL for >6 mo for persons >5 yo.
- Pregnancy
- Current active infection
Immunoglobulin preparations interfere with serologic response to MMR. If possible, give MMR at least 2 weeks before giving immunoglobulin.
TB: If the PPD test is not given on the same day as or before the MMR, wait 4-6 weeks after the MMR or MMRV vaccine before placing the PPD.
In children receiving high-dose (2mg/kg/day or >20mg/day) oral corticosteroids for >14 days, delay MMR for at least 1 month after completion of corticosteroid therapy.
International travel or US areas that are high risk (California, New York, Washington, New Jersey, Michigan)
- Infants 6-11 months: 1 dose before departure (does not count to 2-dose series). Revaccinate with 2 doses at 12-15 mo and 2nd dose at school entry 4-6yo
Measles post-exposure prophylaxis: - see “infectious rashes”
- MMR vaccine (for immunocompetent infants >12mo) within 72 hours of exposure
- OR immunoglobulin (for immunocompromised, pregnant without evidence of immunity, infants <12mo) within 6 days of exposure

Answer 62

A

Varicella

1st dose at 12-15mo, 2nd dose at 4-6yo.
Minimum Interval
- For <13yo, 12 weeks apart
- If >13yo, if not administered during same visit, 4 weeks apart
CI:
- Anaphylaxis to neomycin
- Anaphylaxis to gelatin
- Pregnancy
- Immunocompromised children, except those with impaired immunity (see MMR)
- Children receiving high-dose oral steroids, ( >2 weeks of >20mg/day or prednisone >2mg/kg/day in children <10kg), delay varicella vaccination for at least 1 month
Other altering circumstances:
- Recent blood transfusion or immune globulin therapy - antibodies in blood products can block the immune response
- Antiviral therapy - varicella virus is susceptible to acyclovir, valacyclovir, and famciclovir. These antivirals should be avoided 1 day prior to vaccine until 21 days after administration
- Aspirin therapy - therapy should be avoided for at least 6 weeks after varivax administration bc of the association between aspirin (salicylates), varicella infection, and Reye syndrome

Answer 63

A

MMRV

Children 12-23 mo are twice as likely to have a febrile seizure 5-12 days following MMRV
MMRV is the preferred preparation for the 1st dose in children >48 months of age and for the 2nd dose at any age (15mo - 12yo) in order to minimize the number of injections.
MMR and varicella can be simultaneously administered at separate sites; however, if they are not administered during the same visit, they must be separated by >28 days
Children with HIV receive MMR and varicella at 12mo of age unless they are severely immunocompromised

Answer 64

A

PCV13 and Hib are not routinely given to healthy children after 59mo of age

Answer 65

A

ActHib
- 4th dose is only necessary for 12-59mo who received 3 doses before the 1st birthday

If pt has not received recommended doses, catch-up vaccination is recommended
- Only 1 dose of Hib is required between 15-60 mo, regardless of previous immunization status. If 1st dose is given >15mo age, then no further doses are needed.
Latest can receive is age 5yo (unless HIV, asplenia, immunocompromised)
- Hib vaccine is not recommended for unvaccinated immunocompetent children >5yo

*- 1 dose ActHib is recommended for unvaccinated/partially vaccinated children >5 yo with immunocompromising conditions, including those with functional or anatomic asplenia or HIV infection.

Answer 66

A

Conjugated Pneumococcal PCV-13

4th dose is only necessary for children 12-59mo who received 3 doses before 12mo or for children at high risk who received 3 doses at any age
Unvaccinated or incompletely vaccinated, healthy children 24-59 mo of age (>2yo) should receive a single dose of PCV13.

PCV13 For 2-6yo high risk patients:
- Unvaccinated/<3 PCV13 doses require 2 doses of PCV13 8 weeks apart
- If received 3 previous doses of PCV13, only 1 additional dose
6-18yo at high risk never received PCV13/PPSV23 should receive 1 dose of PCV13 followed by PPSV23 at least 8 weeks later and a 2nd dose of PPSV23 5 years after the 1st

Answer 67

A

Pneumococcal polysaccharide PPSV23
- For children 24-71mo in high-risk groups who have completed the recommended number of PCV13 doses, PPSV23 is recommended at 2 years of age (and at least 8 weeks after the most recent dose of PCV13), followed by a 2nd dose 5 years later for the subset of children with immunocompromising conditions, sickle cell disease, or other hemoglobinopathies, or functional/anatomic asplenia.

2-6yo: PPSV23 #1, at least 8 weeks after most recent PCV13
7yo or in 5 years from 1st dose: PPSV23 #2 for immunocompromised, sickle cell disease, other hemoglobinopathies, functional/anatomic asplenia, HIV, chronic renal failure, nephrotic syndrome

Answer 68

A

Meningococcal Quadrivalent ACWY (Menactra, Menveo)

Recommended for all US children at 11-12 yo adolescent visit, with a booster dose at age 16yo to enhance protection during the period of highest risk (18-23yo, esp college freshman).
- Administer vaccine at 13-18 years if not previously vaccinated
  - If the first dose is administered at 13-15 years, a booster dose is recommended at 16-18 years.
  - If the first dose is administered at >16 years, a booster dose is not indicated.

High Risk: Complement deficiencies, functional/anatomic asplenia (sickle cell disease), HIV infection, travel to country with high rates, military recruits

High Risk with NORMAL Splenic function
2-24mo:
- MenHibrix (Hib-MenCY): 2, 4, 6, and 12-15mo
- Menveo (MCV4): 2, 4, 6, and 12-15mo
- Menactra (MCV4): 2 dose (3 mo apart at 9-23 mo)
2yo-10yo
- 2 dose series of Menveo or Menactra (2 mo apart)
>11yo
- 2 dose series of Menveo or Menactra (2 mo apart)

High Risk with ASPLENIA

2-18mo:
- Menveo or MenHibrix: 2, 4, 6, 12-15mo
- Previously unimmunized 19-23mo (2 doses Menveo 3mo apart)
Do NOT administer Menactra until >4 weeks after completion of all PCV13 (bc interference)

Answer 69

A

Meningococcal B (Bexsero, Trumenba)

Recommended only in children >10 yo at increased risk for meningococcal disease.
- For children >10yo with asplenia (anatomical or functional), persistent complement component deficiency, or HIV who have not received a complete set of meningococcal vaccinations, administer the 2-dose MenB4C or the 3-dose MenB-FHbp.

Answer 70

A

Sports Preparticipation
Consider referral if 1 or more of the hx or physical exam elements are positive
- Syncope occurring with exertional activities is extremely concerning symptoms that merits additional evaluation for underlying heart disease
- Bradycardia (unless HR <30 beats/min) and 1st degree bundle branch block are examples of findings considered to be normal variants in young athletes that might otherwise be of concern.

AAP does not recommend participation in power lifting, body building, or 1-repetition maximum lift exercises by children who are skeletally immature.

Answer 71

A

Conditions that have life-threatening complications and therefore restrict sports participation include

Hypertrophic cardiomyopathy
Prolonged QT interval
Aortic stenosis
Coronary artery anomalies
Myocarditis
Uncontrolled Stage 2 hypertension
Fever (increases risk of heat illness)
Concussion (if still symptomatic)

Answer 72

A

Conditions that require a treatment plan for sports participation include

Asthma
Hypertension
Diabetes mellitus
Eating disorders
Musculoskeletal disorders/injuries
Concussion

Answer 73

A

Side effects of caffeine:

Diuretic, resulting in increased UOP during and after an exercise.
Myocardial infarction, convulsions, cardiac arrest, arrhythmias, anaphylaxis, spontaneous abortion, renal and liver impairment, and psychiatric disorders associated with heavy consumption of energy drinks.
Massive overuse of beverages by US soldiers has caused insomnia (<4h of sleep/night) and sleep disruption due to stress and illness

Answer 74

A

Athletes are considered functionally 1-eyed if they have corrected vision of worse than 20/40 in 1 eye.

Sports that are considered high risk for eye injury and would require protective eyewear for participation: Baseball, basketball, hockey, lacrosse, and racket sports
Sports that are higher-risk for eye injury and functionally one-eye athletes should not participate in these even with appropriate goggles: Wrestling, full-contact martial arts, boxing

Answer 75

A

Conditions that require special considerations

Down syndrome - Predisposition to atlantoaxial (C1-C2) instability and must be examined for this. If exam is abnormal and/or patients are asymptomatic, order cervical imaging and a pediatric neurosurgeon or ortho consult.
- While atlantoaxial instability is a concern in children with trisomy 21, a screening XR is no longer indicated.
Seizure disorder - Should not participate in free climbing, hang-gliding, or scuba diving. Water sports are fine if seizure disorder is well controlled and there is adequate supervision. Certain sports - such as horse-back riding, harnessed rock climbing, and gymnastics - are permissible if precautions are taken.
Type 1 diabetes - Can participate in sport activities but must closely monitor their blood glucose levels before, during, and after exercise (for up to 12 hours).
Hypertension
- Children and adolescents with elevated BP (preHTN) or stage 1 HTN may participate in competitive sports once HTNive target organ effects (including LV hypertrophy) and risk have been assessed
  - It is important to remember that athletic conditioning itself may lead to LV hypertrophy; distinguishing between pathologic and physiologic changes may be difficult.
- AHA and AAP more specifically recommend that athletes with stage 2 HTN should be restricted from high static activity until BP is under control.
Marfan syndrome - Can typically participate in low-moderate intensity exercise (eg bowling, walking). Contact sports and scuba diving are not advisable, secondary to risk of cardiovascular bleed/lens dislocation and precipitating a pneumothorax, respectively.
Sickle cell trait - increased risk of rhabdomyolysis with intense physical activity

Answer 76

A

CRAFFT questionnaire is a quick assessment for adolescents for substance use/abuse

C: Have you ever driven a car while being high or ridden in a car with someone who was driving high?
R: Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
A: Do you ever use alcohol or drugs while you are by yourself (or alone)?
F: Do you ever forget things you did while using alcohol or drugs?
F: Do your family or friends ever tell you that you should cut down on your drinking or drug use?
T: Have you ever gotten into trouble while you were using alcohol or drugs?

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