exam 1 - growth and development

Question 1

well child visit elements

Answer 1

-Growth, development, and nutrition
-Physical examination, screening tests, and immunizations
-Anticipatory guidance
-Evaluation and management of parental concerns

Question 2

normal growth

Answer 2

-Frequent visits in 1st 2 yrs of life are more than physicals!
-Processes of growth and development are intertwined:
-Growth = increase in size
-Development = increase in function of processes related to body and mind
-Genetic makeup and the physical, emotional, and social environment of the individual determine how a child grows and develops throughout childhood
-One goal of pediatrics: Helping each child achieve individual potential through periodically monitoring and screening for the normal progression or abnormalities of growth and development

Question 3

routine office visits

Answer 3

-first week of life (72hrs)
-by 1 month of age
-at 2, 4, 6, 9, 12, 15, and 18 months
-2, 2.5, and 3 years
-then annually through adolescence/young adulthood

Question 4

length/height, wt, head circumference

Answer 4

-obtained at every health visit and compared with statistical norms on growth charts
-Serial measurements (growth trend) -> more useful than single measurements for detecting abnormal growth patterns
-Large shifts in percentiles, large discrepancies in ht, wt, and head circumference (up to 2 years of age) percentiles warrant attention
-with caloric deficit you see decrease in wt first, then ht, then head circumference

Question 5

disorders of growth

Answer 5

-MC reasons for deviant measurements are technical (equipment, human error)
-Variability in body proportions occurs from fetal to adult life -> NORMAL
-kids follow parents’ growth patterns – Familial short stature
-Osseous maturation (often utilized for dx) determined via radiography

Question 6

Constitutional short stature

Answer 6

-Preadolescent/adolescent (by age), starts puberty later than others
-late bloomers

Question 7

Catch-down growth

Answer 7

-Start out in high growth percentiles then decrease wt
-many children assume a lower percentile between 6-18 months until they match their genetic programming; then grow along, new, lower percentiles

Question 8

Catch-up growth

Answer 8

-Infants born SGA/prematurely, ingest more breast milk/formula in first 6 months
-recommend to feed until they cant anymore (vomiting)

Question 9

normal development: evaluation: new born

Answer 9

Primitive neonatal reflexes are unique in the newborn period and can further elucidate/eliminate concerns over asymmetric function
-muscular development (MSK)
-if the primitive reflex isnt going away at a normal time -> problem
-primitive reflexes- NOT ON TEST

Question 10

normal development: evaluation: later infancy

Answer 10

-Progressively able to control posture > proximal musculature > distal musculature
-Orthopedic deformities – Is it fixed, or can it be moved passively into the proper position?
-Evaluation of vision/ocular movements is important to prevent strabismus
-muscle weakness in eye -> strabismus -> anopia (vision loss)

Question 11

normal development: evaluation: school age/pre-adolescent

Answer 11

Comprehensive sports H&P that includes a careful examination of the cardiovascular system

Question 12

normal development: evaluation: adolescence

Answer 12

-Annual comprehensive health assessments to ensure progression through puberty without major problems
-Sexual maturity, scoliosis/orthopedic screening, and obesity

Question 13

developmental milestones/screening

Answer 13

-Compare pts behavior with normal kids
-Developmental Surveillance: at every visit -> comparing skill levels to lists of milestones
-Developmental Screening: use screening tests to identify pts who require further dx assess (CDC recommends at 9, 18, and 30 months)
-MC screeners includes Ages and Stages Questionnaires and Parents’ Evaluation of Developmental States (PEDS)
-After 6th birthday – adolescence, developmental assessment -> asking ab school performance
-With adolescents, emphasis placed on building physician relationship distinct from parental relationship

Question 14

autism screening

Answer 14

-Mandated for all children at 18 and 24 months of age
-Modified Checklist for Autism in Toddlers – Revised (M-CHAT-R)
-If demonstrates > 2 of 3 total behaviors -> further assessment with interview algorithm is indicated to distinguish normal variant behaviors from those children needing a referral for definitive testing
-EARLIER YOU FIND THE BETTER

Question 15

language screening

Answer 15

-if speech or language delay -> must consider hearing deficit and screening
-Dysfluency (stuttering) is common in a 3-4 yo (unless accompanied by tics or unusual posturing) -> want to get out all their thoughts
-by age 5-6 yo it should go away

Question 16

developmental milestones: 1-2 months

Answer 16

-Regards faces and follows objects through visual field/tracks past midline
-dolls eyes are normal
-Becomes alert in response to sound/voice- hearing
-Holds head erect and lifts head - tummy time
-Turns from side to back
-Drops toys
-Parent reported:
-Recognizes parents
-Engages in vocalizations
-Smiles responsively

Question 17

developmental milestones: 3-5 months

Answer 17

-Lifts up on hands, rolls front to back- proximal arm muscles
-Sits with support
-Reaches for/grasps cube (raking), brings object to mouth
-Cooing, squealing (not using lips)
-Makes “raspberry” sound (spitting)
-Parent reported:
-Laughs
-Anticipates food on sight

Question 18

developmental milestones: 6-8 months

Answer 18

-Sits alone for short period
-Passes object from hand to hand in midline
-Imitates “bye-bye”
-Feeds self/holds bottle (learned)
-Babbles
-Parent reported:
-Rolls from back to stomach (using legs/hips)
-Inhibited by “no”

Question 19

developmental milestones: 9-11 months

Answer 19

-Pulls to stand (alone)
-Pincer grasp- choking
-Imitates pat-a-cake and peek-a-boo
-Separation anxiety
-Two-syllable sounds
-Parent reported:
-Walks by supporting self on furniture
-Follows 1-step verbal commands (“come here,” “give it to me”)

Question 20

developmental milestones: 12 months

Answer 20

-Walks independently
-Releases cube into cup after demonstration
-Tries to build tower of 2 cubes
-Says “mama” and “dada” with meaning
-Gives toys on request
-Parent reported:
-Points to desired objects
-Says 1 or 2 words

Question 21

developmental milestones: 18 months

Answer 21

-Runs
-Seats self in chair
-Builds tower of 3-4 cubes
-Throws ball
-Carries and hugs doll
-Parent reported:
-Walks up and down stairs with help
-Says 4-20 words
-Understands 2-step command

Question 22

developmental milestones: 24 months

Answer 22

-Kicks ball, stands on either foot alone
-Jumps off floor with both feet
-Builds tower of 6-7 cubes
-Points to/names objects or pictures
-Speaks in short phrases, 2 words or more
-Uses pronouns
-Parent reported:
-Pulls on simple garment
-Turns pages of book singly
-Play with domestic mimicry
-Verbalizes toilet needs (not full control of bladder yet)

Question 23

developmental milestones: 30 months

Answer 23

-Begins to hop on 1 foot
-Builds tower of 8 cubes
-Holds crayon in fist
-Points to objects described by use
-Uses prepositions
-Refers to self as “I”
-30-36 months- control over bladder
-Parent reported:
-Helps put things away
-Carries on a conversation

Question 24

developmental milestones: 3 years

Answer 24

-Holds crayon with finger
-Builds tower of 9-10 cubes
-Gives first and last name
-Three-word sentences
-Parent reported:
-Rides tricycle using pedals
-Dresses with supervision

Question 25

developmental milestones: 3-4 years

Answer 25

-Climbs stairs with alternating feet -Begins to button and unbutton -“What do you like to do for fun?” (Answers using plurals, personal pronouns, and verbs) -Responds to place toy in, on, or under table -Draws circle when asked to draw person -Knows own sex -Gives full name -Parent reported: -Feeds self at mealtime -Takes off shoes and jacket

Question 26

developmental milestones: 4-5 years (didnt go over)

Answer 26

-Runs and turns without losing balance -Stands on 1 leg for at least 10 seconds -Copies circle/+ sign -Draws a person (head, 2 appendages, 2 eyes) -Buttons clothes and laces shoes -Gives appropriate answers to: “What must you do if you are sleepy, hungry, cold? -Knows the days of the week -school age -Parent reported: -Self care at toilet -Plays outside for at least 30 minutes

Question 27

developmental milestones: 5-6 years (didnt go over)

Answer 27

-Can catch a ball -Skips smoothly, heel-to-toe walks -Copies a square -Draws recognizable person with at least 6-8 details -Counts -Knows L/R hand -Can describe favorite TV program in some detail -Parent reported: -Tells age -Performs simple home chores -Goes to school unattended or meets school bus

Question 28

developmental milestones: 6-7 years (didnt go over)

Answer 28

-Copies triangle -Knows morning/afternoon, time -Draws person with 12 details -Reads several 1-syllable printed words -Defines words

Question 29

developmental milestones: 7-8 years (didnt go over)

Answer 29

-Ties shoes -Copies a diamond -Draws person with 16 details -Enhanced reading -Counts by 2s and 5s -Adds and subtracts 1-digit numbers

Question 30

developmental milestones: 8-9 years (didnt go over)

Answer 30

-Defines words better than by use (an orange is a fruit) -Enhanced reading -Borrowing and carrying processes in addition and subtraction

Question 31

developmental milestones: 9-10 years (didnt go over)

Answer 31

-Knows month, day, and year – names months in order (15 seconds, 1 error) -Enhanced reading, sentence construction -Simple multiplication

Question 32

developmental milestones: 10-12 years (didnt go over)

Answer 32

-Enhanced reading, comprehension -Multiplication and simple division

Question 33

developmental milestones: 12-15 years (didnt go over)

Answer 33

-Enhanced reading, comprehension -Reduce fractions, long division, adds/subtracts fractions

Question 34

recommended screening tests for kids

Answer 34

-Only recommended are newborn metabolic screening with hemoglobin electrophoresis, hearing and vision evaluation, anemia and lead screening, TB testing, and dyslipidemia screening -Metabolic Screening -Mandated in every state -Includes phenylketonuria, galactosemia, congenital hypothyroidism, maple sugar urine disease, and organic aciduria (some states screen for CF) -prevent develop delays -Hemoglobin Electrophoresis -Higher risk for infections/complications -sickle cell -risk to encapsulated bacteria -prophylaxis with PCN until 5yo -vaccines -Critical Congenital Heart Disease Screening -AAP now mandates screening with pulse oximetry of R hand and foot (pass if > 95% and difference is < 3% points; fail if < 90%) -coarctation of the aorta if difference is found -Hearing Evaluation -Performed before discharge from newborn nursery -Screen by 1 month, follow-up (if abnormal) by 3 months, intervention by 6 months -prevent speech delay

Question 35

hearing and vision screening of older children

Answer 35

-Infants and Toddlers: -Inferences from asking parents about response to sound, speech/examining speech, and language development closely -Screened by auditory evoked responses or behavioral audiology (sounds of varying frequencies/intensities filtered into soundproof room) -Inferences about vision made by examining gross motor milestones and PE of eye -Screened by visual evoked responses and/or referral to ophthalmologist -3yo +: -Snellen eye chart (standard or shapes) -Audiologic testing with headphones should begin at 4 yo

Question 36

important milestones

Answer 36

talk, walk, crawling (6-7 months), vocab, mama, dada, 4-20 words

Question 37

anemia screening

Answer 37

-All infants screened at 12 months -> when iron deficiency is greatest (bc of diet change away from formula) -Infants at risk (low birthweight/premature) screened at birth and 4 months -Therapeutic trial of iron may be used when deficiency strongly suspected (no testing required)

Question 38

TB screening

Answer 38

-Screened at 1 month, 6 months, 12 months, then annually -Standard PPD intradermal test used with evaluation 48-72 hours following placement -15 mm induration is positive, 10 mm in high-risk, 5 mm in HIV pts, recent TB contact, healed TB CXR, or immunosuppressed -QuantiFERON-TB Gold blood test is a newer test – single office visit, but pricey

Question 39

lead screening

Answer 39

-CDC recommends routine blood lead screening at 12 and 24 months -Lead intoxication (plumbism) may cause developmental and behavioral abnormalities -Risk factors: living in older homes with cracked/peeling lead-based paint, industrial exposure, use of foreign remedies, and use of pottery with lead paint glaze -affects the CNS -vague symptoms: -Early: Weakness, irritability, weight loss, vomiting, personality changes, ataxia, constipation, headache, and colicky abdominal pain -Late: Developmental delays, convulsions, and coma associated with increased intracranial pressure

Question 40

if lead is +

Answer 40

-Investigation warranted if levels of 20 mcg/dL on 1 time test or persistent 15 mcg/dL over 3-month period (decontamination techniques used once source identified) -Succimer is an oral chelator recommended in asymptomatic children with levels > 45 mcg/dL -IM dimercaprol/BAL and IV calcium sodium edetate in symptomatic children with encephalopathy or levels > 70 mcg/dL

Question 41

cholesterol screen

Answer 41

-AAP recommends dyslipidemia screening for at-risk populations by obtaining a fasting lipid profile -Screening levels are the same for 2-18 years of age (170 mg/dL normal, 170-199 mg/dL borderline, 200 mg/dL is elevated)

Question 42

STI testing

Answer 42

-Sexually experienced adolescents should be screened for STIs and have an HIV test at least once between 16 and 18 -at least an annual evaluation for STIs by physical (genital warts, genital herpes, pediculosis) and lab testing (chlamydia, gonorrhea, syphilis, HIV) -Pap smears at 21 years of age

Question 43

depression screening

Answer 43

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Question 44

immunizations

Answer 44

-Checked at each visit and appropriate ones administered -Live-attenuated: Measles/Mumps/Rubella, Varicella, Influenza (nasal), Polio (PO), Rotavirus!!!!!! -Inactivated/killed viruses: Polio (IM), Hepatitis A, Influenza (IM) -Recombinant: Hepatitis B, HPV -Immunogeneic components of bacteria: Pertussis, H. influenzae type b, N. meningitidis, and S. pneumoniae; including toxoids (Diphtheria, Tetanus) -Schedule includes up to 23 injections in 4-5 visits by 18 months of age -Children behind on immunizations should receive catch-up as rapidly as possible -Infants premature should be vaccinated based on chronological age (same schedule) -Administered following informed consent from parents -he said the main thing to know is the live vaccines -know the chart- ex. 12mo pt presents assuming they are up to date with vaccines -> Which vaccine would you now recommend -passive immunity- breast feeding -active immunity- vaccine

Question 45

immunization catch up schedule

Answer 45

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Question 46

vaccines summed up

Answer 46

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Question 47

anticipatory guidance- birth to 6mo

Answer 47

-Information conveyed to parents verbally, in written materials, or online resources to assist them in facilitating optimal growth and development for their children -burns

Question 48

anticipatory guidance: 9mo-4years

Answer 48

-swim -poisoning- safety locks -2-3 potty training

Question 49

anticipatory guidance: 5-21yo

Answer 49

-sexual development -goals

Question 50

anticipatory guidance: car safety

Answer 50

-MCC of death for infants 1 month to 1 year of age is MVA -Most states have laws mandating use of safety seats until 4yo or at least 40 pounds: -Infants and toddlers in !rear-facing safety! seat until at least 2 years old -Toddlers and preschoolers over age 2 should use forward-facing car seat with harness -School-aged children should use !belt-positioning booster! seat until vehicle seat belt fits properly (4 ft 9 in and between 8-12 year of age) -Older children should always wear lap and shoulder seat belts (protects from air bags)

Question 51

anticipatory guidance: sleep safety

Answer 51

-Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year that remains unexplained after a thorough case investigation -Sudden unexpected infant death syndrome (SUID) is a sudden and unexpected infant death (explained or unexplained) – now the preferred term -Includes deaths due to infection, ingestions, metabolic diseases, cardiac arrhythmias, and trauma -Incidence peaks between ages 2 and 4 months -Most deaths occur at night -Risk factors: Socioeconomically disadvantaged populations (continued prone positioning, sharing beds), preterm birth, low birth weight, recent infection, young maternal age, high maternal parity, maternal tobacco or drug use, and crowded living conditions -Pathological findings most common for SUID deaths from unknown cause (SIDS): Intrathoracic petechiae, mild inflammation/congestion of the respiratory tract, findings consistent with chronic hypoxia prior to death

Question 52

sleep safety tx/prevention!!!!!!

Answer 52

-Back to Sleep initiative has resulted in a 60% decline in SIDS rates since 1990 -Supine positioning -Sleep in parents’ room, close to parents’ bed but on a separate surface designed for infants at least for the first 6 months of life -Remove soft objects/loose bedding, stuffed animals, or wedge positioners from infant’s sleep area -Breastfeeding is recommended -Pacifier at naptime and bedtime -Avoiding cigarette smoking during pregnancy and after birth -Avoid car seats, swings, and baby slings for sleep -Avoid use of adult beds and bed rails (increases risk of suffocation)

Question 53

teething

Answer 53

-can mimic ear infection -Remedies for teething pain: -OTC teething gels or liquids that contain benzocaine -Systemic analgesics -Chewing on teething object (distraction) -Eruption Cysts: Localized, red/purple, round, raised, and smooth lesion, resolved with eruption of tooth (NORMAL) -All children 1yo+ should have dental exam by dentist at least annually and cleaning every 6 months -Preventative measures: Brushing, flossing, concentrated fluoride topical treatments (dental varnish) and acrylic sealants on molars -Recommended PCPs apply dental fluoride varnish to infants and children every 3-6 months between 9 months and 5yo -Fluoridation of water or fluoride supplements in communities that do not have fluoridation are important in prevention of caries

Question 54

colic

Answer 54

-Episodes of uncontrollable crying or fussing in an otherwise healthy infant -Paroxysmal, characterized by facial grimacing, leg flexion, and passing flatus -Wessel rule of threes: -Crying for > 3 hours/day -At least 3 days/week -> 3 weeks -Etiology: Unknown, likely multifactorial -Cow’s milk intolerance -Change in fecal flora -Increase in serotonin secretion -Poor feeding technique -Maternal smoking may be associated

Question 55

colic: guidance and management

Answer 55

-Techniques for calming infants (Dr. Harvey Karp’s “5 Ss”): -Swaddling -Side/stomach holding -Soothing noises -Swinging/slow rhythmic movement -Sucking on pacifier -Educating parents on hunger cues, avoiding excessive caffeine and use of alcohol in nursing mothers, ensuring adequate bottle/nipple flow, and cautioning overfeeding Effectiveness of dietary changes, herbal supplements, and/or medications very limited -Prognosis -No evidence of long-term adverse outcomes for patient or parents -Most serious complication of colic is nonaccidental trauma

Question 56

temper tantrums

Answer 56

-Brief episodes of extreme unpleasant behavior disproportionate to situation, in response to frustration or anger -whining, crying, screaming, stomping, flailing, head banging, hitting, throwing objects, and biting -Etiology -Normal human developmental behavior -1-4 yo have increasing desire for independence and are often unable to effectively communicate physical needs and emotions -Triggers include fatigue, hunger, discomfort, and frustration

Question 57

temper tantrum work up

Answer 57

-History: Evaluate for other behavioral, psychologic, or physiologic conditions -Important to differentiate between typical and atypical tantrums -Physical examination: -Focus on identifying signs of underlying illness and include vision, hearing, and developmental exams -Behavioral observations -Dysmorphic features may reveal a genetic syndrome, skin exam (anemia, nonaccidental trauma), neurologic exam -Laboratory studies: Screening for iron deficiency anemia and lead exposure

Question 58

temper tantrum guidance and management

Answer 58

-Communicate clear, consistent, and developmentally appropriate expectations and consequences -Provide positive reinforcements for good behavior -Maintain routine and structure in a child’s environment -Use distraction techniques -Avoid known triggers -Help children learn to communicate desires, needs, and emotions -Provide children with choices among acceptable alternatives (support autonomy) -Parents should remain calm and meet physical/safety needs without complying to child’s demands, do not punish for tantrum

Question 59

sleep habits

Answer 59

-Behavioral sleep disorders most prevalent from infancy through preschool age -Affect 30% of children, with bedtime resistance in 10-15% of toddlers and difficulty falling/staying asleep in 20-30% of school-age children and 10% in adolescents -Behavioral Insomnia of Childhood -Sleep-onset association subtype: Frequent, prolonged nighttime awakenings that occur in infants/children -Limit-setting subtype: Bedtime resistance or refusal that stems from caregiver’s unwillingness or inability to enforce bedtime rules/expectations

Question 60

sleep habits workup and tx

Answer 60

-History -Sleep habits, typical bedtime, sleep onset/wake times, and schedule variation from day to day -Description of sleep environment (type of bed, sharing bed, ambient noise, and temperature) -Dietary practices and household routines -Physical examination to rule out organic causes of sleep disturbances -Prevention and Treatment -Consistent and appropriate bedtime routine/close attention to sleep hygiene -Behavioral interventions mainstay of treatment -Systematic ignoring: Not responding to a child’s demands for parental attention at bedtime -Strategic napping -Positive reinforcement -Behavioral therapy (nighttime fears) -No FDA approved medications for treating insomnia in children